State Pharmaceutical Assistance "Wrap Around" Programs in 2006-08: 
Helping to Make Medicare Part D Easier and More Affordable

An analysis of laws and regulations providing state-funded prescription drug wrap around benefits, coordination and ease of enrollment for 1.5+ million residents in more than 20 states. 

Updated: November 2007; reposted March 2008

• monthly premiums (up to a "standard" of about $25/month for 2008)
•  co-insurance or co-payments (often 25% of purchase price)

• annual deductibles (up to $265 in 2007; up to $275 in 2008)
• the "gap" or "doughnut hole" ($2,400 to $5,451.25 /year in 2007; starts at $2,510 up to $5,726.25 in 2008)

Deductible

Pay first $265 per year; some plans = $0-$150.
(deductible was $250 in '06)

State pays SPAP covered drugs from first dollar.

No state contribution.

coinsurance or copay(brand example)

Pay 25% of cost.

State pays 100% of copayment over $5.

No state contribution. 

Coverage gap
$2,400 -$5,451.25 /year ('07)

Pay 100% out-of-pocket (up to $3,051.25; up from $2,850 in '06)

State pays 80% for Rx over $1,750.

State pays 100% above copayments of $10 for generics or $25 for preferred brand name.

New state requirements for enrollees

 n/a

Must enroll in Part D plan if eligible; must apply for low-income subsidy.

If eligible for Medicare low-income subsidy must apply and use it.

Statutory Authority

Medicare Modernization Act, Dec. 2003.

Illinois SB 973 of 2005.

Nevada AB 495 and AB 524 of 2005.

Delaware

SPAP, M

’05 law

200%

Yes

Yes

No

Yes

No

Yes

Illinois

SPAP+

’05 law

216.5%

Yes

Yes

Yes 1

Yes

No

Yes

Maine

SPAP, M

’05 law

185%

Yes

Yes

Yes 1

Yes

No

Yes

Massachusetts

SPAP, M

’05 law

500%

Yes

Yes

Yes

Yes

Yes 500%

Yes 188%

Yes 5

Montana

SPAP

’05 law, new

200%

Yes

Yes

No

No

No

Yes

Nevada

SPAP

’05 law

236.4%

Yes

No

No

Yes

No

Yes

New Jersey

SPAP

'05 law

316.2%

Yes

Yes

Yes

Yes

Yes 316%

Yes

Option

Rhode Island

SPAP

pending

392%

4

Yes

4

Yes

Yes 392%

No

Vermont

SPAP+

’05 law

225%

Yes 1

Yes

Yes

3

No

Yes

Yes

Wisconsin

SPAP+

’05 waiver

240%

No

No

6

No

No

No

Texas - KHC

SPAP

150%

Yes

Yes

Yes

No

Yes

No

Alaska is one of six states to create a first-time pharmaceutical subsidy program after the enactment of the MMA.  As such, it is intended primarily as a supplemental, wrap around benefit, aimed only at residents aged 65 and over, with incomes up to 175% of Alaska’s special FPL.   The law authorizes the state to pay premiums and deductibles toward Part D plan costs or toward equivalent insurance premiums.

State laws – 2004 & 2005

First subsidy enacted in 2004; Wrap around enacted in HB 106, as Chapter 89, signed August 8, 2005.  Text: http://www.legis.state.ak.us/PDF/24/Bills/HB0106Z.PDF
Program effective date: January 1, 2006.

State eligibility 

Residents age 65.  For SeniorCare Cash Assistance, income limit is $16,133 for an individual and $21,641 for a 2-person household; liquid assets must be below $6,000 for an individual and $9,000 for a couple.  For SeniorCare Prescription Drug Assistance, income limit is $20,913 for an individual and $28,053 for a 2-person household.

Disabilities coverage

Persons with disabilities under age 65 are not eligible for state benefits.

Benefit example

Under the Cash Assistance program, qualified residents can receive $120/month cash assistance (up to $1,400 annually).  Under the Prescription Drug Assistance program, qualified residents can receive up to $670 for annual premiums and deductibles for Medicare or comparable insurance.

Special Features

AK will pay the same premium and deductible share toward employer retiree plans.

Requirements & Limits

If state funds are “insufficient”, the state may reduce or eliminate payments, first for deductibles, then premiums.  A “sister” cash assistance program for seniors up to 135% FPL has first priority for funds.  Individuals must be enrolled in some type of Rx plan – includes Part D PDP or Medicare Advantage; also group health, FEHBP, VA, Medigap or “any other private plan” identified by the state as equivalent to a Part D plan.  A person with no premium or deductible cannot receive benefits; this disqualifies Medicare enrollees with income under 135% of FPL.  Disabled under age 65, or residents in institutions or nursing facilities, are not eligible. Residents with income under 135%% FPL (about 7,000) are eligible for up to $1,440 annual direct cash benefit, not earmarked for Rx, but available to use for special assistance low-income copays of $1-$5.  Asset limit is $50,000 (individual) and $100,000 (couple).

SPAP legal status

Qualified SPAP approved by CMS; payments count toward enrollee TrOOP, 10/05.

Est. # of Beneficiaries 

122 enrolled in Prescription Drug Assistance program as of 7/1/06.

7,112 enrolled in the Cash Assistance program ($120/month subsidy) as of 7/1/06.

Funding source

State law creates the Alaska Senior Care Fund, based on transfer of any 2004 funds and future annual state appropriations.

2006 & Future issues

Parts of the SeniorCare program sunset in June 2007 unless extended by the legislature.  Annual funding is subject to available funds and legislative appropriations.

2005 estimates included 7,000 seniors served by the Cash Assistance program and 4,000 seniors served by the Prescription Drug Assistance program.  The Department will be assessing enrollment figures in August 2006.

Contact & Information


Web site

Alaska Department of Health and Social Services
Policy & Admin. Contact: Sherry Hill, (907) 465-1618, Cell (907) 321-2838 Beneficiary Contacts: 1-800-478-6065 (Anchorage 907-269-3680.)
www.hss.state.ak.us/dsds/seniorcaresio.htm

In June 2006, FY 2006-2007 budget bill includes $1.5 million appropriations for payment of Part D copays for dual eligible enrollees, including acute, long-term care and behavioral health, administered by AHCCCS, the Medicaid agency.  "The intent of the Legislature is that all Part D copayments will be covered as a state subsidy."  Program begins October 1, 2006

State law(s)

HB 2863, signed as Chapter 344, 6/21/06 - FY 2006-2007 budget bill includes $1.5 million appropriations for payment of 100% of the Part D copays for dual eligible enrollees, including acute, long-term care and behavioral health, administered by AHCCCS, the Medicaid agency.  "The intent of the Legislature is that all Part D copayments will be covered as a state subsidy." 

Eligibility

Medicaid dual-eligibles, up to 200% of federal poverty.  Medicare Part D enrollment is required but separate state enrollment in the copayment plan is not required. The program will be operational as of October 1, 2006

An estimated 87,000 dual-eligibles will be eligible.  (9/06)

Connecticut’s long-time subsidy program, ConnPACE, is authorized to wrap around and coordinate benefits between ConnPACE and MMA, including allowing the state to apply on behalf of current state subsidy enrollees.  All enrollees eligible for Medicare must join Part D, with the state covering all premiums, all but $30 of the deductible, and costs above the $2,400 coverage gap.

State law(s)

1986: Program established by CGL sec 17b-491 et seq.
2005: Public Act 05-280, signed June 27, 2005.

State eligibility

Resident with annual income up to $22,300 for an individual; $30,100 for a married couple, who is 65 or older or who is over age 18 and disabled ($ as of mid 2005).  Must have “no other plan of insurance or assistance” except Medicare Part D.  A $30 annual registration fee required.  An annual inflation adjustment is tied to Social Security income, to the nearest $100.

Disabilities coverage

Persons with disabilities between the ages of 18-64 are eligible for state benefits, including coverage during the 2-year waiting period for federal Medicare eligibility.

Benefit example

The state will pay 100% of the Part D premiums (average $370 year,) plus all out-of-pocket coinsurance and deductible above the standard ConnPACE $30 annual fee and copayment requirement of $16.25 per prescription. There is no yearly dollar limit on the amount of prescriptions covered.  A person with $5000 in annual Rx expenses might receive up to $3,500 in state-funded benefits.

Special features

The Program will cover products “that are not Part D drugs” as defined in the MMA, if the patient or prescriber appeals for an "exception."  The state payment rate “may be made at (A) the lowest price established” by a PDP for a preferred drug in the same class, with the beneficiary responsible for any higher balance; (B) the ConnPACE price if lower than the PDP price.  Authorizes automatic application for low income subsidy benefit and state-initiated enrollment in Part D plans, with the state selecting a Part D plan designated by the Commissioner if a recipient has not done so.  Provides that the applicant or recipient “shall appoint the (state) commissioner” for the purpose of appeals and denials.  Full SPAP benefits are available until an individual is enrolled in Medicare Rx.  Once enrolled, SPAP will provide wraparound coverage.

Requirements & Limits

Enrollment in Part D is a requirement for all who are eligible, as of 1/1/06. The State now requires asset as well as income reporting beginning July 1, 2005.  The State will not provide coverage for drugs purchased outside of the formulary for the selected PDP.

SPAP legal status

Qualified SPAP approved by CMS; payments count toward enrollee TrOOP, 10/05.

Est. # of beneficiaries

49,396 enrolled as of June 30, 2005; estimate 48,000 are both Medicare + ConnPACE enrolled.

Funding source

For FY 2004 ConnPACE’s covered program costs by receiving $1,569,360 in fees from participants and $32,009,150 from drug manufacturers, for a net cost of $60,517,110 from state revenue funds.

2006 & future issues

All SPAP members are slated to be enrolled by 5/15/06.

Contact & information



Web site

Connecticut Department of Social Services
Pharmacy Unit, Medical Care Administration
Medicare Part D information-English  |  Spanish
toll-free eligibility information: 1-800-423-5026 or 860-832-9265
http://www.connpace.com/

Delaware’s six-year old subsidy program has established a wrap around benefit for Medicare enrollees, to cover premiums, deductibles and drugs purchased in the coverage gap over $2,400, up to a maximum of $2,500 in state funds per calendar year.

State law(s) 1999 to 2005

1999: SB 6; benefits and enrollment began in 2000; benefits are coordinated with the private Nemours Foundation prescription benefit; their enrollees are not eligible for DPAP.
2005: SB 18 established the wrap around program, effective January 1, 2006.

Eligibility

Must be residents, at least 65 years old or qualify for Social Security Disability benefits. Maximum income eligibility limit is set at 200% of the Federal Poverty Level (FPL). Couples are counted as two individuals. Individuals with income over 200% of FPL can qualify if they have prescription costs exceeding 40% of their income.

Disabilities coverage

Persons with disabilities under age 65 are eligible for state benefits, including coverage during the 2-year waiting period for federal Medicare eligibility.

Benefit example

An individual with $5,000 in prescription costs annually could receive $370 for premiums, $250 for the annual deductible and up to $1,880 for gap coverage for a total up to $2,500 in state funds.

Special features

Requires that the Medicare benefit will be the primary source of benefits for those who are eligible for it.  An original requirement to enroll in Medicare Part D by 12/31/05 was extended to 3/31/06.  [News article 1/4/06] The state law restricts covered drugs to those from manufacturers that agree to provide a drug rebate back to the state, based on Medicaid rebate methodology.  [NOTE: This rebate requirement is not consistent with the structure of Medicare PDP plans.]  May cover some drugs that are excluded from Part D that have received prior authorization, including OTC drugs, benzodiazepines and barbiturates.

Requirements & Limits

DPAP provides up to $2500 per individual per calendar year.  Beneficiaries must enroll in Medicare by March 31, 2006 to be eligible for DPAP payments.  They must copay $5 or 25% of the cost of each prescription, whichever is greater; the state will not pay any portion of Medicare Part D copayments.

SPAP legal status

Qualified SPAP approved by CMS; payments count toward enrollee TrOOP, 10/05.

Est. # of beneficiaries 

9,684 enrollees as of 7/1/06; an estimated 95% are eligible for Medicare. 

Funding source

Tobacco settlement funds.

2006 & future issues

The state requirement for a manufacturer drug rebate on all reimbursed products may require reexamination under federal law.

Contact & information
Web site

The Division of Social Services
Phone: 255-9500 or 1-800-372-2022
FAX: (302) 255-4454
http://www.dhss.delaware.gov/dhss/dss/dpap.html

Hawaii established its first subsidy program in July 2005.  The program is focused on Medicare eligible seniors and persons with disabilities only with income up to 100% of FPL. ($11,750 in '07).  It will assist eligible individuals "in defraying their cost" of prescriptions through a wrap around benefit within Medicare Part D.  The program is not yet operational.

State law(s)

2005: SB 802, signed on 7/8/05 as Act 209; authorized to be operational as of 1/1/06.

Eligibility

1) Residents age 65 and over or disabled with annual income up to 100% of FPL ($11,750 in 2007.)  The statute does not specify Medicare eligible as a state eligibility requirement.

Disabilities coverage

Persons with disabilities under age 65 are eligible for state benefits, once they fully qualify for Medicare after the federal two-year waiting period.

Benefit  example

A senior not on Medicaid with income just under 100% FPL might receive coverage for copayments due on each purchase.

Special features

The program may facilitate enrollment and coordination of benefits.  The law specifies that the program “may pay all or some of the deductibles, co-insurance payments, premiums and copayments.” Most dual eligibles under 150% FPL will have limited financial obligations under Medicare Part D.  
   Legislative Note: The final Senate legislation to create an SPAP provided for coverage up to 150% of FPL.  A conference committee reduced that number to 100% FPL.  The matter may be subject to further action in 2006.

Requirements & Limits

This program is not operational as of January 2007 and the start date is not yet established.  Enrollees must meet an asset test “as defined by the MMA”, and not be enrolled in a Medicare Advantage plan, a retired employee plan receiving a Medicare benefit payment, or any private sector plan or insurance paying for prescription drugs. Hawaii already uses 100% FPL as the Medicaid aged-disabled level, so few, if any, state benefits may be available to Medicare enrollees.

SPAP legal status

Not currently certified as a qualified SPAP; payments do not count toward enrollee TrOOP according to CMS, as of 11/8/05.

Est. # of beneficiaries

n/a

Funding source

Earmarks all manufacturer rebates established by the 2005 Act (in sec. 346B(g)) for use by the new program.

2006 & future issues

The program is not yet operational for 2006.
The low 100% FPL maximum income had been 150% FPL in the legislation, and might be revisited by the legislature.  The manufacturer rebate feature, the funding source and the asset test may require reexamination to comply with CMS and PDP structures.

Contact & information

Web site

Department of Human Services 
Policy information only: (808) 692-8134

A 2005 state law updated three existing state pharmacy assistance programs and created the “No Senior or Person with Disabilities Left Behind” plan as a Medicare wrap around that allows the state to pay premiums, deductibles and gap coverage for up to 241,000 seniors and persons with disabilities.  The state also will continue coverage programs for non-Medicare adults.

State law(s)

2005: SB 973, signed 6/29/05; effective 1/1/06
IL also has had a Pharmacy Plus Medicaid 1115 waiver for certain residents under 200% of FPL.

Eligibility

Illinois Cares Rx Plus is available to residents age 65 or older, with income up to $19,600 for individuals or $26,400 for a married couple. (200% FPL as of 2/06).  Illinois Cares Rx Plus will cover prescription drugs that were previously covered by SeniorCare, including some drugs that are excluded from Medicare coverage by law such as benzodiazepines.

Illinois Cares Rx Basic is available up to $21,218 for individual, up to 28,480 for a couple (approximately 216% FPL), or up to $35,740 if you are filing an application for you, your spouse and one other qualified additional resident or for you and at least two qualified additional residents.

Disabilities coverage

Persons with disabilities under age 65 are eligible for state benefits, including coverage during the 2-year waiting period for federal Medicare eligibility.

Benefit example

A senior with annual income above 150% of federal poverty with $5,000 in drug expenses could receive 100% of the standard Part D premium and deductible costs, including the 25% co-insurance and gap coverage, totaling about $3,000 in state-paid costs.

Special features

State law authorizes auto-assignment; 2005 state enrollees will be automatically enrolled in wrap around features, with one application for all programs; the state will use its preferred drug list where applicable.  The state’s Pharmacy Plus 1115 waiver presents special conditions for some enrollees under 200% of FPL.  IL has two qualified SPAPs for TrOOP calculations.

Requirements & Limits

Enrollees with incomes between 200% and 225% of FPL are covered only for drugs for treatment of 11 conditions including: Alzheimer’s, arthritis, cancer, diabetes, glaucoma, cardiovascular disease, lung and smoking-related diseases, osteoporosis, Parkinson’s or multiple sclerosis.  
     All Illinois Cares Rx clients enrolled in a PDP must follow their PDP’s formulary. "Illinois Cares Rx will not cover Part D covered drugs just because they are not on the client’s PDP’s formulary." 
     People with Original Medicare must apply for Low Income Subsidy (“Extra Help”) and must enroll in one of two Medicare prescription drug plans coordinating with Illinois Cares Rx: PacifiCare Saver Plan or the AARP Medicare Rx of United HealthCare Insurance Company.

SPAP legal status

Qualified SPAP approved by CMS; payments count toward enrollee TrOOP.

Est. # of beneficiaries

247,592 enrollees as of 6/30/06.

Funding source

State general funds.

2006 & future issues

A participant must reapply to Illinois Cares Rx before July 2006 to continue receiving benefits in 2007.

Contact & information
Web site

Telephone 217 524-0084; In IL, toll-free 800 624-2459
http://www.illinoiscaresrx.com/ 
http://www.cbrx.il.gov/ 
Illinois Rx Buying Club Member Services  toll-free 866-215-3462 (TTY) 866-215-3479
http://www.illinoisrxbuyingclub.com/

The Hoosier Rx program, founded in 2000, continues in 2006.  The current structure provides up to $1,200 per year for seniors age 65 and over with annual incomes up to 150 percent of federal poverty guidelines.  The program now offers wrap around benefits for Medicare PDP monthly premiums for plans working with HoosierRx and a $250 annual allowance to use towards any deductible and/or co-pays.  These changes are not yet in state statute.

State law(s)

HB 1251; HB 1325 (2005);  
IN Admin. Code, Title 405, Art. 6

Eligibility

Must be a resident, age 65 and older, have Medicare Part A and/or Part B, and have a yearly income up to, but not exceeding $14,940 for an individual or $20,040 for a married couple living together (150% FPL as of 2/06.)  Participants must enroll in one of the Medicare Prescription Drug Plans working with HoosierRx.  Participants must apply with the Social Security Administration for extra help from Medicare.  HoosierRx can assist those that get partial extra help from Medicare and those denied for Medicare’s extra help due to resources.

Disabilities coverage

Persons with disabilities under age 65 are not eligible for state benefits, as of 11/05.

Benefit example

HoosierRx will help low-income seniors make up the difference between their out-of-pocket costs and the Medicare coverage.  For individuals with partial Medicare extra help, HoosierRx will pay the remaining premium amount, that is not covered by Medicare, within one of the plans that are working with HoosierRx.  HoosierRx will also pay a maximum of $250 yearly toward a $50 deductible and/or co-pays.  For individuals with no Medicare extra help, HoosierRx will pay the monthly premium of one of the plans working with HoosierRx.  HoosierRx will also pay $250 yearly toward a deductible and/or co-pays.

Special features

HB 1325 seeks coverage for Medicare deductibles, premiums and drug costs not covered by the federal benefit or federal PDP plans. HoosierRx currently does not require the use of prior authorization, preferred drug lists or mandatory generics.
The 2005 law authorizes future coverage up to 200 percent of federal poverty if recommended and approved.

A separate program,  "Rx for Indiana" is a collaborative effort by Gov. Mitch Daniels, numerous local and statewide organizations and the pharmaceutical industry and is not a subsidy program, but rather a clearinghouse that pulls together all federal, state and private companies that offer discounted drugs and services.  Rx for Indiana helps people of all ages find and apply for assistance through pharmaceutical manufacturers for help with brand name drugs.  Each company program has different benefits and covers different drugs, providing free or discounted prescription drugs to eligible patients.

Requirements & Limits

The maximum annual benefit is $1,200; the state pays up to 75% of drug costs, the enrollee is responsible for the remaining 25%.

In order to be eligible for HoosierRx, enrollee is required to apply for the "Medicare Extra Help" through Social Security to pay for Medicare Part D, and must receive either a "Notice of Award" or "Notice of Denial" from Social Security.  A "Notice of Denial" must be because resources are above the limit established by law and a "Notice of Award" must state that enrollee is receiving a partial extra help subsidy to help pay for Medicare Part D premium. 

SPAP legal status

Not currently certified as a qualified SPAP; payments do not count toward enrollee TrOOP according to CMS, as of 11/8/05.

Est. # of beneficiaries 

1,500 enrollees as of 7/1/06 (no non-Medicare, no full dual-eligibles).   The program anticipates increased enrollment by 12/06. 

As of 7/11/06, the Rx for Indiana telephone hotline logged 76,649 calls and the website logged 99,148 hits.  141,592 patients initially qualified for assistance and approximately 81% were eventually matched to a program.

Funding source

Money from the Tobacco Settlement Fund has been allotted for this program for the next three years, after which the Indiana Legislature must allocate budget money for an additional 20 years.  Hoosier Rx currently receives no funding from the Indiana General Fund.

2006 & future issues

HoosierRx has restructured the program and, as of 7/1/06, there is no more wrap around benefit ($250 for co-pays and premium).  HoosierRx will now pay a higher premium amount for enrollees instead of using the wrap around benefit. 

Contact & information
Web site

Hoosier Rx Program (toll free) at 1-866-267-4679
Senior Health Insurance Information Program counselors (toll-free) at 1-800-452-4800.
http://www.in.gov/fssa/elderly/hoosierrx/ 
http://www.rxforindiana.org/

The Kansas Medicaid program is reported to pay limited state assistance with the cost of copayments to Medicare-Medicaid dual-eligible enrollees*

State law(s)

Kansas Medicaid agency

Eligibility

Medicaid dual-eligibles under 135% of federal poverty.

Kentucky passed a 2005 law to implement a state pharmaceutical assistance program.  However, it has not been implemented. The state intended to contract with a third party, to direct dual or lower income beneficiaries into the state preferred plan. The contractor would negotiate for drug rebates.  However, CMS clarified that these types of arrangements did not meet the criteria of an SPAP under Medicare.  Kentucky has not moved forward with the SPAP as of January 1, 2006.

State law(s)

2005: SB 23 signed into law March 18, 2005

Eligibility

Includes persons 65 or older or disabled and enrolled in Medicare, with a household income up to 150% of the poverty level, meeting the asset test, and not having other prescription drug coverage.

Benefit best example

This program is not operational as of August 2006 and the start date is not yet established.

Special features

Would allow the Department of Medicaid Services to determine drugs to be covered by the plan, and allow department to negotiate with manufacturers for rebates.

Requirements & Limits

A memo from CMS Deputy Administrator Leslie Norwalk to potential Part D Sponsors and State Medicaid Directors stated that the types of arrangements with rebates and a preferred plan did not meet the criteria of an SPAP under Medicare.
By state law, benefits are to be limited to the amount of state appropriations, with the program as a payor of last resort.

Est. # of beneficiaries

none enrolled

Funding source

State funds, subject to annual appropriation.

2006 & future issues

Features not approved by CMS in 2005 prevented implementation.  The legislature likely will review such terms and conditions.

Contact & information
Web site

Not available; not yet operational.
Department of Medicaid Services
 

Maine has run one or more senior pharmacy assistance programs since 1975.   For 2006, the state will offer wrap around benefits for Medicare eligibles, including coverage for premiums, one-half of the deductible and 80% of the coverage gap.

State law(s)

2005: LB 1325, signed by governor as Chapter 401, 6/17/05;
State agency given emergency regulatory authority

Eligibility

For subsidized benefits: Maine residents age 62 and older, or persons with disabilities age 19-61, with annual income of 185%  ($18,888 for 2007).  If a person spends 40% of yearly income on prescription drugs, the income limit is 200% FPL.  ($20,420 for 2007)  MSP program-asset test converted 9,000

Disabilities coverage

Persons with disabilities under age 65 are eligible for state benefits, including coverage during the 2-year waiting period for federal Medicare eligibility.

Benefit example

Wrap around benefits apply to dual eligibles & three levels based on income.  Some pharmaceuticals excluded by Medicare will continue to be covered for everyone, as covered in 2005. The state will pay 1/2 of the copay up to $10 - $15 for all dual eligibles.  For those in assisted living, the state will pay 100% of all copays.  The program has eliminated its asset limit, which will qualify an estimated 9,000 new residents.  Those residents for whom the state pays Part B Medicare premiums, the state also will now cover Part D premiums.  Copays are covered 50% with a cap of $10; also will cover 100% premium; 50% of deductible; and 80% of the coverage gap (doughnut hole), for the 14 categories of treatments specified in state law.  Enrollees pay 20% of the coverage gap (over $2,250).

Special features

The Department of Human Services has emergency regulatory authority to make further adjustments in benefits and eligibility.
In April '06, a Supplemental Budget was enacted with broad bipartisan support. It includes $10.7 million to ensure that seniors who received prescription drug benefits under MaineCare or the state’s Drugs for the Elderly program would not lose benefits or have to pay more because they were switched to the federal Medicare Part D program. The budget provides extensive ongoing wraparound benefit for Medicare Part D enrollees including both Medicaid dual eligibles and participants in the state elderly low-cost drug program members who are transitioning to Medicare Part D. Also provides for the state purchase of a higher than benchmark plan when a person needs a drug that is not on their plan's formulary and they have an initial denial of an exception for coverage; eliminates all co-payments for persons in all levels of private non-medical institutions (boarding and group homes); and eliminates all co-pays on generics.

Requirements & Limits

SPAP legal status

Qualified SPAP approved by CMS; payments count toward enrollee TrOOP, 10/05

Est. # of beneficiaries 

38,133 enrollees, as of 6/1/07 (approx. 28,000 enrolled in Medicare Part D)
47,867 dual-eligibles matched in 2006

Funding source

State appropriations.

2006 & future issues

The benefit details were not specified in statute in 2005, so proposed changes are possible during the 2006 session.

Contact & information
Web site

Tel.: 207 287-2674; toll-free: 888 600-2466
http://www.maine.gov/dhhs/beas/medbook.htm

Maryland has provided some state Rx assistance since 1979.  A 2005 law integrates current state programs by providing Medicare Part D beneficiaries who meet program requirements with a state subsidy authorized for a portion of their Medicare Part D premiums, deductibles, coinsurance payments, and/or copayments.   For 2006-07 the benefit covers up to $25 of the monthly premiums.

State law(s)

2005: HB 324 & SB 282, enacted into law May 2005.  Authorizes a state subsidy  for a portion of their Medicare Part D premiums, deductibles, coinsurance payments, and/or copayments. 

Eligibility

2005 members grandfathered in as of 12/31/05. 
Resident for 6 months; at or below 300% FPL ($29,400 for individual) and enrolled in Medicare; but must not be qualified for full federal "extra help" LIS benefit.

Disabilities coverage

Persons with disabilities under age 65 are eligible for state benefits, including coverage during the 2-year waiting period for federal Medicare eligibility.

Benefit example

Successful applicants can receive up to $25 per month towards the cost of their monthly Medicare Rx or Medicare Advantage Prescription Drug premium.

Special features

1) The MD discount and subsidy programs of 2005 were folded into the new Primary Care Program.  The new Primary Care Program was authorized under Maryland's revised 1115 waiver renewed earlier this year.  People enrolled now get prescription drugs and more replacing need for a separate drug program. Maryland also has an Rx discount plan, changed as of 1/1/06 to serve non-Medicare residents, mostly under age 65.
2) The Maryland Pharmacy Program (MPP) Provides services for the following programs: Medicaid, HealthChoice receive most mental drugs; all other drugs are provided by HealthChoice Managed Care Organizations (MCOs);  Primary Adult Care (PAC); Family Planning receive only contraceptives and Medicare Part D fully dual eligible Medicare beneficiaries receive most drugs excluded from Medicare Coverage.
3) SPDAP will attempt to coordinate with an individuals' selected Medicare Rx or Medicare Advantage plan for the direct subsidy of the monthly premium, so that enrollees are only billed by the Medicare plan for any premium which exceeds the state’s monthly subsidy of $25.

Requirements & Limits

Must be enrolled in Part D, or be auto enrolled by early January 2006 into one of 21 standard PDPs. 

SPAP legal status

Qualified SPAP approved by CMS; payments count toward enrollee TrOOP, 10/05

Est. # of beneficiaries

35,500 enrollees, as of 7/1/06 

Funding source

Care First tax assessment pays for the program. (3^rd party administrator of the program)

2006 & future issues

During the 2006 session, the Maryland Legislature passed HB 702, which prohibits the subsidy required under the Senior Prescription Drug Assistance Program from exceeding a specified amount in specified fiscal years.  The bill also authorizes a subsidy for copayments and deductibles.

Contact & information
Web site

To request an application, call the Maryland Pharmacy Program toll-free, 1-800-226-2142
SPDAP program: http://www.marylandspdap.com/
The Maryland Pharmacy Program (MPP): www.dhmh.state.md.us/mma/mpap/
Application and income: http://marylandspdap.com/v2_0a/Portals/1/Docs_MarylandSPDAP/SPDAP%20Application0906.pdf

Massachusetts is one of two states with a sliding-scale subsidized prescription insurance plan, with no income limit for seniors but with a low-income limit for persons with disabilities.  The newly enacted wrap around for 2006 makes Medicare Part D the required primary coverage, with state help for deductible, copayment and coverage gap payments. The state was the first to gain approval in 2005 for automatic enrollment in Part D on a random basis.

State law(s)

MGL Ch. 19A, §39
H 4200, §27 signed into law by governor as Chapter 45 of 2005 on 6/30/05.
Chapter 175 of 2005 signed into law by governor on 12/30/05
H 5000 of 2006 signed into law by governor on 7/8/06

Eligibility

Open to all non-Medicaid seniors age 65 and older of all incomes, and low income persons with disabilities (see below).  No asset test.  For persons with Medicare, income limit is up to 500% FPL; without Medicare, there is no income limit.  Prescription Advantage will continue to offer prescription drug insurance coverage for people not eligible for Medicare.

Disabilities coverage

Persons with disabilities under age 65 with a special maximum income of 188% FPL and not more than 40 work hours per month are eligible for state benefits, including coverage during the 2-year waiting period for federal Medicare eligibility.

Benefit  example

The state will help pay deductible, copayment and coverage gap payments, with at least four categories of income levels receiving sliding scale financial benefits. The details are not specified in statute.  Examples:
> Full duals (under 135% FPL) will not receive state help.
> Between 135%-188% FPL: state pays premiums up to $363.24 annually and copays above $7 generic or $18 brand-name.  Out-of pocket expenses capped at $1,300 to $1,440.
> Between 188%-225% FPL: State pays premium share up to $123 annually and copays above $12 generic or $30 brand-name.  Out of pocket expenses capped at $1,800 annually.
> Between 225% FPL-300% FPL: State pays only copays above $12 generic or $30 brand-name.  Out of pocket expenses capped at $2,150 annually.
> Between 300%-500% FPL: State may provide gap coverage after a cap of $2,870.

Special features

On August 29, 2005, CMS formally approved the Massachusetts plan to automatically enroll state members into lower cost drug plans, with 5 plans initially approved for this process. Members in “Medicare Advantage” plans (Tufts, Fallon, Harvard Pilgrim and Blue Cross) will not be automatically enrolled.  Prescription Advantage will pay for benzodiazepines (excluded from Medicare coverage) but will not cover other drugs excluded from Medicare coverage, such as barbiturates and over-the-counter drugs.

Requirements & Limits

As of 1/1/06 the state requires enrollment in a Medicare Part D plan or Medicare Advantage plan and application for federal low-income subsidy if eligible. 

SPAP legal status

Qualified SPAP approved by CMS; payments count toward enrollee TrOOP, 10/05.

Est. # of beneficiaries 

Total enrollment in Prescription Advantage is 71,003, as of 7/1/06. 
Estimated 70,229 eligible for Medicare; 774 are non-Medicare.

Funding source

Tobacco tax; general funds. The FY06 state budget includes $92.2 million for subsidies and operations for 12 months beginning 7/1/05.

2006 & future issues

The multi-level sliding scale benefits may be examined to simplify the structure.  The state-only insurance product for the much smaller pool of 3,000 people may be subject to evaluation as well.

Contact & information

Web site

MA Executive Office of Elder Affairs; 617 727-7750
Prescription Advantage Customer Service - toll-free: 800 243-4636.
http://www.mass.gov/Eelders/docs/prescription_advantage_medicare_wrap_factsheet.pdf ;
http://www.mass.gov/portal/site/massgovportal/menuitem.db805ceae7e631c14db4a11030468a0c/?
pageID=elderssubtopic&L=3&L0=Home&L1=Health+Care&L2=Prescription+
Advantage&sid=Eelders

Missouri's 2005 law coordinates state pharmaceutical assistance with MMA.  It establishes a newly defined "Missouri RX" subsidy plan for residents with income up to 200% of federal poverty. The Plan "may pay all or some of the deductibles, coinsurance, payments, premiums and copayments" required by Part D; the state may select one or more preferred PDP plans for purposes of the coordination of benefits between the program and the Medicare Part D drug benefit. Beginning 2006, Medicare disabled under 65 are added as eligible.

State law. 2005

2005: SB 539 was signed into law by governor on April 26, 2005.
The old “Senior Rx Plan” is being phased out as soon as the MMA Part D benefit is “fully implemented” as certified by the state.

State eligibility

 For 2007, residents with income up to 200% of federal poverty or dual-eligibles.  In 2006, residents with maximum income up to 150% of federal poverty or dual-eligibles. The old Senior Rx Program members and all dual eligibles (eligible for both Medicare and Medicaid) were automatically enrolled into MoRx. There is no cost for this enrollment, nor is there any additional paperwork. To receive the benefits of the MoRx program, its members must be enrolled in a Medicare Prescription Drug Plan. Non-duals must not be enrolled in Medicaid. 

Disabilities coverage

As of 2006 persons with disabilities under age 65 are eligible for state benefits, once they fully qualify for Medicare after the federal two-year waiting period.

Benefit  example

"MoRx pays for 50% of members' out of pocket costs remaining after their Medicare Prescription Drug Plan pays. It pays for 50% of the deductible, 50% of the co-pays before the coverage gap, 50% of the coverage gap, and 50% of the co-pays in the catastrophic coverage."

Special Features

The new Missouri Rx Plan will no longer require an enrollment fee or deductible. It will provide "wrap around" coverage to those who have Medicare A and/or B and are enrolled in a Medicare Rx Prescription Drug plan. Missouri Rx benefits will help pay a percentage of member's out of pocket drug costs remaining after using their Medicare Rx Prescription Drug plan.

Requirements & Limits

The (2005) Senior Rx Plan provided eligibility for age 65 residents with single income up to $17,000, or a couple up to $23,000 (approximately 177% of FPL), with a copay of 40% and a $250-500 deductible, depending on income. The application fee was $25-35 per year.  The new 2006 Plan will not cover current enrollees with incomes over $14,355 (150% FPL).  The new law does not specify the level of state contribution for deductibles and copayments.  SSDI recipients not yet eligible for Medicare are not eligible for state benefits. The 2005 program had a maximum benefit of $5,000 per member per year and did not cover drugs manufactured by companies that do not participate in the state rebate program, or Over the Counter (OTC) products, Drugs used for weight gain or anorexia, Drugs used to promote fertility, Cosmetic and Hair Growth agents, Cough and Cold Preparations, Prescription Strength Vitamins, Barbiturates (Phenobarbital and Derivatives typically used to treat insomnia), Benzodiazepines (Typically used to treat anxiety such as Valium or Xanax), Insulin Syringes and Diabetic Supplies, Food Supplements (ex. Ensure), Medical Equipment, Devices and Supplies.  
[Source: Drug Coverage,  Missouri Senior Rx, 12/19/05]  Note: 2006 FPL will increase by 2.4%

SPAP legal status

Qualified SPAP approved by CMS; payments count toward enrollee TrOOP, 12/21/05.

Est. # of Beneficiaries

161,645 enrollees (as of 7/15/06)
148,348 are dual-eligibles tranferred from State Medicaid Program
13,297 were members of former program called Missouri Senior Rx (auto-enrolled into Missouri Rx Program)

Funding source

2006 & Future issues

2005 enrollees over 150% FPL were expected to transfer to a federal-only benefit plan in 2006, where the costs of benefits will be somewhat similar to their old benefit, with higher premium but 25% copay instead of 40%.  On November 1, 2006, Governor Blunt announced expansion to cover residents up to 200% of FPL.

Contact & Information

Web site

Missouri Rx,
205 Jefferson Street, Room 1310, Jefferson City, MO 65101
Telephone: 1-800-375-1406 (Toll-free)
http://www.dss.missouri.gov/dms/pharmacy/mo_rx.htm
News: "Blunt announces expansion of Missouri Rx program" 11/1/06.

This newly created state program is designed to help qualified Medicare residents pay for Medicare prescription drug premiums, up to $397 annually.

State law(s)

2005: SB 324, signed into law as Chapter 282 of 2005, 5/10/05.

Eligibility

MT Resident, enrolled in Medicare Part D plan, with annual family income less than about $19,600 if single or about $26,400 if married and living together. (200% FPL in 2006.)  Also requires enrollees to have applied for Extra Help if annual family income is less than $14,700 if single or $19,800 if married and living together. Big Sky Rx will inform applicants when they appear close to being eligible for Extra Help.

Disabilities coverage

As of 2006 persons with disabilities under age 65 are eligible for state benefits, once they fully qualify for Medicare after the federal two-year waiting period.

Benefit example

Pays up to $33.11 of Medicare Part D premium, for an annual maximum of $397.00.

Special features

Requirements & Limits

Must be enrolled in Medicare Part D and file an application for low-income Extra Help every year.  The program does not pay for individual drug purchases.

SPAP legal status

Qualified SPAP approved by CMS; payments count toward enrollee TrOOP, 10/05.

Est. # of beneficiaries

3,018 enrollees, as of 7/1/06 

Funding source

SB 324 put aside $8.75m for 3 programs, of which approximately $7- 7.5M is from the tobacco tax.

2006 & future issues

Concerned about growth factor in premiums and other unknowns.

Contact & information
Web site

Brochure: http://www.dphhs.mt.gov/prescriptiondrug/applicationcover.pdf or
http://www.dphhs.mt.gov/prescriptiondrug/bigskyrxbrochurefinal.pdf
Application: http://www.dphhs.mt.gov/prescriptiondrug/bigskyrxapplication.pdf
Homepage: http://www.bigskyrx.mt.gov/
 

The Nebraska Medicaid program is reported to pay limited state assistance with the cost of copayments to Medicare-Medicaid dual-eligible enrollees*

State law(s)

Nebraska Medicaid agency

Eligibility

Medicaid dual-eligibles under 135% of federal poverty.

Nevada’s first-in-the-nation state-negotiated Rx insurance subsidy program was one model for the federal Medicare benefit, with its reliance on private insurers.  State law enacted in 2005 requires the state to wrap around and coordinate prescription drug services provided by the state with those provided by Medicare, with a goal of maintaining present coverage "to the extent allowed by federal law," as well as maximizing prescription drug coverage and the use of federal funds. 

State law(s)

2005:  AB 495 and AB 524 enacted and signed June 10, 2005

Eligibility

Senior Rx is available for residents age 62 or older at the time of application with annual income not more than $24,118 for individual or $31,396 for a married household (figures effective July 1, 2006.)

Disability Rx is available for residents age 18-61 with annual income not more than $24,118 for individual or $31,396 for a married household (figures effective July 1, 2006.)

For those eligible for Medicare, Senior Rx and Disability Rx will help pay for Part D PDP premiums and prescription drug costs after Part D coverage limit is reached.  For those not eligible for Medicare, there is no monthly premium, no deductible, drug coverage of $10 for generics and $25 for brand, and an annual coverage limit of $5,100.  The State provides assistance with Medicare Part D expenses for members who are eligible for Part D and a cost-sharing benefit for members who are not eligible for Part D.

Disabilities coverage

Persons with disabilities under age 65 are eligible for state benefits, including coverage during the 2-year waiting period for federal Medicare eligibility.

Benefit example

The state will pay up to $281.52 annually toward annual Part D premiums (100% of $23.46/month for a basic plan) and will provide gap coverage for 100% of the expenditures over $2250 /per year (a state contribution up to $2,850).  Maximum annual state benefit = $5,100.00.

Special features

The department may waive the eligibility requirements for an individual based on income, disability or extreme financial hardship, certified in a written request.  State-only insurance policies remain available for non-Medicare enrollees.  For 2006 only there may be a special emergency fund to assist with deductibles.  “We want to make sure no one is worse off” said Mike Willden, Director of Health and Human Services.

Requirements & Limits

One year state residence required prior to applying. Senior Rx insurance will no longer be available to Medicare enrollees as of January 1, 2006; those eligible for extra help “must apply for that help and use it”. The state will not pay copayments or annual deductibles, except for a 2006 special emergency fund. Enrollees pay $10 copayment for generics or $25 copayment for preferred brand name pharmaceuticals. Senior Rx has a $5,100 annual maximum insurance benefit.

SPAP legal status

Qualified SPAP approved by CMS; payments count toward enrollee TrOOP, 10/05

Est. # of beneficiaries 

7,284 enrolled in Senior Rx
147 active enrollees in Disability Rx (268 on waiting list)

Funding source

Tobacco settlement funds, limited to 30% of revenues or 1.5% of total in the Fund for a Healthy Nevada. (NRS 439.630(c))

2006 & future issues

The legislature requested a departmental report by 11/05 regarding the state amount for premium payments. The state program continues to serve a small population of non-Medicare residents (age 62-64 or with certain disabilities) with an insurance policy product.
[NOTE: A Notice to members on the NV website states that deductibles and copayments will not be paid.]

Contact & information
Web site

 http://nevadaseniorrx.nv.gov/

New Hampshire created its first SPAP in 2005, specifically designed to wrap around Medicare Part D, aimed at duals and non-duals up to 150 percent of federal poverty.  The program will be authorized to pay all or some of the deductibles, coinsurance, premiums and copayments, and products not covered by Medicare.   The program is not yet in effect, pending implementation approval by a legislative fiscal committee and CMS.

State law(s)

2005: SB 163, signed as Chapter 294 of 2005 on July 26, 2005

Eligibility

Age 65 or older or disabled and receiving Social Security and enrolled in Medicare, with household income up to 150% of FPL and meeting the asset test.  Medicaid dual eligibles receive initial enrollment priority.  90-day state residence required.

Disabilities coverage

As of 2006, persons with disabilities under age 65 are eligible for state benefits, once they fully qualify for Medicare after the federal two-year waiting period.

Benefit  example

This program is not operational as of February 2006.
The details of the state share to "pay all or some of the deductibles, coinsurance, premiums and copayments, and products not covered by Medicare" are not yet available.
NOTE: As of January 1, 2006 the NH Medicaid program will provide coverage for pharmaceuticals not covered by Medicare, only for dual-eligibles.

Special features

The program was intended to launch January 1, 2006. Wrap around coverage “shall be provided” for prescription drugs excluded from definition of Medicare Part D drugs, but are covered by Medicaid. The law provides that the state “may” require Medicaid-level rebates, and enroll beneficiaries into a preferred Medicare Part D plan. (These provisions have not been approved for implementation by the NH Fiscal Committee or by CMS nationally).

Requirements & Limits

Requires CMS approval of the program (294:4 (II)).  The program “shall be the payor of last resort” with enrollees also enrolled in a Part D plan; benefits “shall be limited to the amount of appropriations.” No benefits are available to Medicare Advantage plan members or MMA qualified retirement plans.

SPAP legal status

Not operational as of December 2006.  Not currently certified as a qualified SPAP; state payments do not count toward enrollee TrOOP according to CMS, as of 12/06.

Est. # of beneficiaries

n/a

Funding source

Annual appropriations.

2006 & future issues

The entire program requires final "sign-off" by the legislature's Fiscal Committee, and CMS.
The asset test is not defined in state law. The level or degree of state contribution per enrollee is not stated in law.  The preferred PDP and rebate language is inconsistent with CMS requirements as of 11/05.

Contact & information
Web site

Not yet operational.
NH Office of Medicaid Business and Policy is 603-271-5254
[no online information as of 12/05]

New Jersey's two operational pharmacy assistance programs served over 200,000 resident in 2005, and celebrated a 30th anniversary since they enacted their original, first-in-the nation senior program in 1975.   For 2006, N.J. requires that Medicare eligibles enroll in a Part D plan, with the state covering cost-sharing, deductibles and coverage gap costs in Medicare Part D, as well as premiums for those eligible for PAAD.

State law(s)

1975  Ch.30: 4D-20 et seq.] web link
2001 S.6; chapter 96 of 2001
2005: S 3000, signed as Chapter 132, 7/2/05)

Eligibility

Age 65 or older or over 18 and disabled receiving SSDI benefits. 
PAAD: Income up to $21,850 for an individual and up to $26,791 for a couple (214.1% of FPL in 2006).  PAAD beneficiaries are also required to enroll in a Medicare Part D Prescription Drug Plan.  They will not have to pay premiums, deductibles, or any out-of-pocket costs beyond the regular PAAD $5.00 co-payment.

Senior Gold: Income between $21,850 and $31,850 annually for an individual and between $26,791 and $36,791 for a couple (316.2% of FPL in 2006).  Members pay a co-payment of $15 plus 50% of the remaining cost of each covered prescription.  Once members reach annual out-of-pocket expenses exceeding $2,000 for single persons or $3,000 for married couples, they pay only a flat $15 co-payment per prescription.

Disabilities coverage

Persons with disabilities under age 65 are eligible for state benefits, including coverage during the 2-year waiting period for federal Medicare eligibility.

Benefit example

NJ will pay all premiums, deductibles and cost-sharing above the $5 per prescription copayment for PAAD enrollees. A person with $5,000 in annual Rx expenses might receive up to $3,600 in state-funded benefits.

Special features

The state PAAD benefit "shall only be available to cover the beneficiary cost share to in-network pharmacies and for deductible and coverage gap costs associated with enrollment in Medicare Part D for beneficiaries of the PAAD and Senior Gold programs, and for Medicare Part D premium costs for PAAD beneficiaries.

Requirements & Limits

2005 law specifies that if a PAAD beneficiary declines enrollment in any Part D plan, the beneficiary shall be barred from all benefits of the state PAAD Program. It makes the PAAD program the authorized representative for coordinating benefits with the Medicare Drug Program, including "application for the premium and cost-sharing subsidies on behalf of eligible program beneficiaries, pursuit of appeals, grievances, or coverage determinations, facilitated enrollment in a prescription drug plan or MA-PDP plan."  The higher-income Senior Gold discount plan, with 50% enrollee copays, does not require Part D enrollment for continued state coverage.

SPAP legal status

Qualified SPAP approved by CMS; payments count toward enrollee TrOOP, 10/05.

Est. # of beneficiaries

PAAD “will continue to provide benefits to more than 190,000 residents in 2006.”
Senior Gold “will continue to provide benefits to nearly 30,000 residents in 2006.”

Funding source

State casino tax revenue; general appropriations.

2006 & future issues

Contact & information

Web site

Dept. of Health & Senior Services
Telephone: 609 588-7048;  Toll-free in NJ: 800 792-9745
PAAD: http://www.state.nj.us/health/seniorbenefits/pbp/paad-home.shtml
Senior Gold: http://www.state.nj.us/health/seniorbenefits/documents/seniorgold_factsheet.pdf
 

New York’s EPIC plan, the nation’s largest state subsidy program, has enacted a wrap around plan that will pay for most drug costs not paid by Medicare, including deductibles, co-insurance or copayments, the gap in coverage above $2,250 and products not covered by Medicare.  Enrollees remain responsible for state-established copayments up to $20, fees or deductibles (up to $1,200).

State law(s)

2005: S 3668 signed as Chapter 58 on 4/12/05.; 2006: A 9554; sections became law by veto override as Chapter 54, 4/26/06

Eligibility

Seniors age 65 or older with annual income up to $35,000 if single or $50,000 if married.  (Equal to approximately 336% and 357% of FPL in 2008.)  As of July 1, 2007 a new EPIC Law Requires Medicare Part D Enrollment.  There is a sliding scale fee from $8 to $300 annually for lower income enrollees; a deductible is required for individuals over $20,000 annual income. Seniors who receive full Medicaid benefits are not eligible for EPIC benefits.

Disabilities coverage

Persons with disabilities under age 65 are not eligible for state benefits.

Benefit example

Members of the EPIC Fee Plan will receive free Medicare Part D coverage because EPIC will pay the monthly premiums (up to $24.45 a month, the average cost of a basic Medicare drug plan) for any Part D plan.  The EPIC Deductible plan is available to single seniors with income between $20,001 and $35,000, and married seniors with income between $26,001 and $50,000.   Those enrolled pay full price for their prescriptions until they meet an annual deductible which is also based on income.
An enrollee with annual income of 200% of FPL with $5,000 in Rx expenses might receive up to $2,900 in gap coverage and partial copayment assistance. 

Governor: allowed temporary administrative edits as of 1/6/06 for 2 weeks.  
2006 emergency law, A 9462, to pay pharmacists, retroactive from 1/1/06 until "no longer necessary."  (Passed legislature; vetoed by Governor, veto overridden to become law, 2/7/06)

Special features

EPIC fee will be waived for those with Medicare Low Income Subsidy. EPIC can be combined with other plans to lower costs at the retail counter. For example, if a PDP requires a $25 copay for a $100 product, EPIC will cover the $25 expense and charge the enrollee only $7 as a copay. Co-branding agreements are being sought with all PDPs willing to meet criteria for seamless coordination with EPIC benefits.  The state is using “Intelligent Random Assignment” for all low income Subsidy members.  EPIC is considered “creditable drug coverage” at least equal to Part D, so state enrollees will not face a premium penalty if they do not enroll in Part D by May 2006.

Separate from EPIC, the NY Medicaid program, in limited circumstances "will provide an additional Medicaid 'wrap around' benefit for drugs not covered by the PDP in addition to the federally excludable drug categories. This will only occur after the prescriber has requested an exception (the first step in an appeal) with the PDP and has received a denial. To assure that the Medicare prescription benefit has been maximized prior to billing NYS Medicaid, the Medicare Verification System (MVS) was developed."  [View description online]

Requirements & Limits

EPIC will not cover Medicare premiums. A sliding scale annual fee of $8 (under $6k annually) to $230 (up to $20k annually) is required.  Those with incomes from $20k to $50k are responsible for an annual sliding scale deductible of $530 to $1,230 instead of a fee.  Per prescription copayments range from $3 to $20, averaging about 20% of the price. Persons with disabilities under age 65 are not eligible.

SPAP legal status

Qualified SPAP approved by CMS; payments count toward enrollee TrOOP, 10/05.

Est. # of beneficiaries 

371,000 enrolled as of 7/2006.  Of the total, 162,00 are enrolled in a Medicare Part D plan.  Of those 162,000, there are approx. 62,000 eligible for full Low Income Subsidy.

Funding source

Annual state appropriations.

2006 & future issues

The complex financial sliding scales of fees and deductibles in EPIC may present special challenges in calculating costs and benefits among private plans.    The legislature's FY 2006-07 budget, A 9554, authorizes continuing Medicaid wraparound coverage for duals until January 14, 2007.

Contact & information
Web site

EPIC Office
Telephone: 518 452-6828; Toll-free in NY: 800 332-3742
http://www.health.state.ny.us/health_care/epic/index.htm

State law(s)

Eligibility

NC resident age 65 or over, enrolled in Medicare Part D plan.

Disabilities coverage

Persons with disabilities under age 65 are not eligible for state benefits.

Benefit example

A senior may receive up to $18 a month or $216 annually toward premiums.

Special features

New program starts January 1, 2007. 

Requirements & Limits

In 2007, NC Part D premiums range from $17.80 to $85.90 per month

SPAP legal status

Senior Care was a Qualified SPAP approved by CMS; payments count toward enrollee TrOOP, 10/05.

Est. # of beneficiaries 

enrollment opened mid-November, 2006

Funding source

$24 million committed for 2007 from the North Caroline Health & Wellness Trust Fund

Future issues

The program may require further legislative authorization and apprpriations in 2007.

Contact & information
Web site

For consumer assistance, call 1-888-488-6279
Web site: www.ncrx.gov

The Pennsylvania subsidy plan has operated since 1985 and will continue in 2006.  PACE Plus Medicare is a new program designed toconvert the state’s drug assistance plans into a supplemental program that will “wrap around” private Medicare Part D prescription drug plans.   It gives the state the authority to act as a representative for its PACE and PACENET enrollees in matters relating to Medicare Part D, enrolling beneficiaries into Medicare Part D plans, pay Part D premiums, and apply for low-income subsidies on behalf of PACE and PACENET members.

State law(s)

1985 law
2006: SB 1188, signed as Act 111 on 7/7/06.

Eligibility

Residents age 65 or older.  PACE annual income up to $14,500 single; $17,700 married (Approximately 148% FPL in 2006.)

PACENET catastrophic benefit option, annual income up to $23,500 single; 31,500 married (Approximately 240% FPL in 2006.)

Disabilities coverage

Persons with disabilities under age 65 are not eligible for state benefits.

Benefit example

The Legislature made changes to law in order for PACE to pay premiums; as the wraparound portion of PACE and PACENET.  PACE members pay an average of 14% of total drug costs, which average $2,400 per person annually.  Forthe first nine months of 2006, PACE members pay a co-payment of $6 for generic and $9 for brand-name drugs.  PACENET members pay a co-payment of $8 for generic and $15 for brand-name drugs. 

The new PACE Plus Medicare program will drop the $40 monthly deductible PACENET enrollees pay in favor of a monthly premium, not to exceed the regional benchmark Part D premium of $32.54. The premium will be treated like a deductible and will be collected by pharmacies. About 15,000 PACENET enrollees who do not normally use drugs may face higher costs under this new plan design. 

Special features

The program allows members to be also enrolled in another prescription or heath plan. PACE is “creditable coverage,” meaning that enrollees who choose not to enroll in a Part D plan by May 15, 2005 will not face a premium penalty later.
    PA law requires a manufacturer rebate for PACE purchases.  For 2006 the program is "intending to collect 'best price' rebates on any claim that PACE pays in full during the deductible period, coverage cap, or off formulary. On all other claims PACE will not be seeking a rebate." (4/4/06).
     Enrollment in Part D is optional for new PACE Plus Medicare.  There will be six selected stand-alone Part D plans for the new auto-assign/auto-enroll process.  Auto-assignment began on 7/19/06 and auto-enrollment is expected to begin on 8/8/06.  Enrollments will be effective on 9/1/06.  

    In September 2005, Pennsylvania launched the Independent Drug Information Service in 28 counties, including Allegheny, Beaver and Lawrence, aiming to educate doctors about prescription drug benefits by helping them choose the most clinically appropriate medications for their patients.  The goal is to improve the prescription process by informing physicians on various drugs, rather than promoting a certain product. The concept was designed by Dr. Jerry Avorn, a professor of medicine at Harvard University.  In conjunction with the PACE program, eight specially trained drug information consultants began meeting with doctors at their practices last year. The consultants visit 25 to 30 doctors a month, mainly physicians whose prescribing habits don't mesh with their peers. The doctors are given evidence-based information on various types of drugs and brand-name alternatives are discussed.  As of April 2006 there have been 2,300 visits to physicians and about 420 educational sessions.  [news article 4/10/06]
"Outreach medication education in Pennsylvania: A non-commercial source of evidence-based information about medication choices for physicians", Presentation by Michele Spetman, M.S., M.P.H.: May 19, 2006 (in PPT format)

Requirements & Limits

Medicaid enrollees and public Retired Employees Health Plan (REHP) enrollees are not allowed to enroll in PACE or PACENET. 

SPAP legal status

Qualified SPAP approved by CMS; payments count toward enrollee TrOOP, 12/05.

Est. # of beneficiaries

315,000 total (March 2006)
In late 2005: 195,000 PACE, with an estimated 80,000 eligible for extra help in 2006 + 98,000 PACENET.
It is anticipated that, because of the new PACE Plus Medicare program, the PACE and PACENET programs will be expanded by 35 percent to cover an additional 120,000 enrollees by 2007. 

Funding source

PA State Lottery and tobacco settlement funds; also a small part covered by general funds.

2006 & future issues

State law on PACE was changed in July 2006 by the legislature's SB 1188 of 2006.  The state discussed choosing to have an “unqualified SPAP” by selecting a preferred plan or plans.  State will base premium assistance from average of standard PA plans.

SB 1188 was signed into law (as Act 111) on 7/7/06. 

Contact & information
Web site

PA Dept. of Aging
555 Walnut Street, 5th Floor, Harrisburg, PA  17101
Residents toll-free 1-800-225-7223 or (717) 787-7313; FAX: 717-772-2730
http://www.aging.state.pa.us/aging/cwp/view.asp?a=293&q=252885
http://www.aging.state.pa.us/aging/cwp/view.asp?a=293&q=252808
http://pda-apprise.org/providers/  Email: aging@state.pa.us
Independent Drug Information Service, at http://rxfacts.org/home.html
News article:  New drug program to start for Pa. seniors - Philadelphia Inquirer, 9/1/06

The currently operational RIPAE program will continue in 2006.  The details of wrap around and coordination of benefits were not available as of the publication date of this report.

State law(s)

1985, 2003: RI General Laws §42-66.2-5

Eligibility 

Minimum age is 65, or between 55 and 64 if disabled and receiving Social Security Disability Income (SSDI) payments.  There are three levels of coverage, based on income: 15% discount if over 65 or age 55-64 and disabled with income of $23,506-$41,136 (individual) and $29,384-$47,012 (couple); 30% discount for over 65 with income $18,725-$23,505 (individual) and $23,408-$29,383 (couple); and 60% discount for over 65 with income up to $18,724 (individual) and up to $23,407 (couple) (392.6% of FPL for 2006). 

Disabilities coverage

Disabled individuals under age 55 are not eligible for state benefits.

Benefit example

The details of Part D wrap around and coordination of benefits were not available as of the publication date of this report.  The RIPAE program pays "a portion of the cost of prescriptions used to treat Alzheimer’s disease, arthritis, diabetes (including insulin and syringes for insulin injections), heart problems, depression, anti-infectives, Parkinson’s disease, high blood pressure, cancer, urinary incontinence, circulatory insufficiency, high cholesterol, asthma and chronic respiratory conditions, osteoporosis, glaucoma, and prescription vitamins and mineral supplements for renal patients for eligible Rhode Island residents 65 and older." RIPAE enrollees can purchase all other FDA-approved "Category B" prescriptions (except for those used to treat cosmetic conditions) at the RIPAE-discounted price.

Special features 

Excludes income spent on medical expenses if greater than 3% of total income.

Residents between 55 and 64 who are receiving SSDI payments can purchase medications at a 15% discount.  There is no state co-payment for these medications.  Income limits for SSDI receipients are $41,136 for individuals and $47,012 for a married couple.

Requirements & Limits

Program is in the process of recertifying members and will pay the usual benefit for those not enrolled in Part D and will provide a wraparound for those who are enrolled in Part D.  Program will pay percentage discount (15%, 30%, and 60%) during the deductible and coverage gap periods, but will not pay for premiums or copays.
[Source: "State Part D Wrap Around for SPAP Beneficiaries," Report by the Centers for Medicare and Medicaid Services, April 5, 2006.]

SPAP legal status

Qualified SPAP approved by CMS; payments count toward enrollee TrOOP, 10/05

Est. # of beneficiaries 

16,000 members, as of 7/1/06

Funding source

State General Revenue Fund (2005)

2006 & future issues

The details of wrap around and coordination of benefits may require legislative and executive branch action and approval in 2006.

Income limits were increased by 4.1% in 2006 to reflect the annual Cost-of-Living Adjustment (COLA) as determined by the Social Security Administration.  Injectible prescription medications used to treat Multiple Sclerosis were added to the list of medications covered under the main category of drugs paid for under RIPAE.  These changes took effect on 7/1/06. 

Contact & information
Web site

Dept. of Elderly Affairs
(401) 222-2880
http://adrc.ohhs.ri.gov/paying/Prescription_Assist.php

The FY 2005-06 budget creates a Gap Assistance Prescription Program for Seniors (GAPS) as of January 1, 2006, to replace the SILVERxCARD subsidy program of 2000-2005.  The new program will coordinate with Medicare Part D in providing assistance to low-income, Medicare-eligible South Carolinians with their prescription drugs costs under Medicare, providing subsidy coverage for annual expenses between $2,250 and $5,100 (the gap not covered by Medicare.)

State law(s)

2005: HB 3716 - Sec. 8-J02, signed into law 6/26/05.

Eligibility

Resident age 65 and over; must not have any other form of prescription drug coverage other than Medicare enrollment.  SILVERxCARD served individuals with annual income up to 200% of FPL ($19,600 for an individual in 2006).

Disabilities coverage

Persons with disabilities under age 65 are not eligible for state benefits.

Benefit example

A senior with $5,000 in annual Rx expenses might receive up to $2,500 in gap coverage.

Special features

New program starts January 1, 2006. 

Requirements & Limits

$500 annual deductible.  Participants must enroll in one of the five commercial PDPs that participate in GAPS. GAPS Medicare PDP Letter.

SPAP legal status

Qualified SPAP approved by CMS; payments count toward enrollee TrOOP, 10/05.

Est. # of beneficiaries 

9,000 enrollees, as 7/1/06

Funding source

Tobacco Settlement Funds.  Pharmacy Plus federal matching funds ended December 2005.

2006 & future issues

Enrollment will likely expand, as the enrollment deadline for PDP's has been extended until November 2006.

Contact & information
Web site

For consumer assistance, call 1-800-834-2680.
http://southcarolina.fhsc.com/beneficiaries/silverxcard/
http://southcarolina.fhsc.com/Beneficiaries/silverxcard/documents.asp

The Department of Human Services State Pharmaceutical Assistance Program provides financial assistance for prescription drug coverage for seniors.  Starting January 1, 2006 The Pharmaceutical Assistance Program (PAP) will provide extra financial assistance to Medicare beneficiaries to help with their drug costs associated with the new Medicare Part D prescription drug coverage.

State law(s)

2005: Bill No. 26-0029 (Act 6749)

Eligibility

Residents age 60 and over with limited income of $18,000 (single) or $30,000 (married) may qualify for help from the program.

Disabilities coverage

No separate coverage available

Benefit example

Will cover the monthly premium, co-pays and the annual deductible expected to be associated with the Medicare Prescription Drug Plan.  Individuals with Medicare with chronic or catastrophic illness can receive extra financial help in paying the premium, co-pay, deductible and other required out-of-pocket expenses.  In order to get the “extra help,” you must first enroll into a Medicare Prescription Drug Plan.

Special features

SPAP will enroll its members into Prescription Drug Plans offered by Member Health, Inc. and United Health Care

Requirements & Limits

Participants cannot have any other major pharmaceutical coverage

SPAP legal status

Qualified SPAP approved by CMS

Est. # of beneficiaries

Approx. 800

Funding source

2006 & future issues

Contact & information
Web site

Marlene Van Beverhoudt, Asst. Admin.
Dept. of Human Services, Office of Senior Citizens Affairs
(340) 774-0930, x. 4118
http://www.ltg.gov.vi/departments/medicare_office/Presciption_Drug_Plan.pdf
http://www.ltg.gov.vi/departments/medicare_office/medicarepdc.html

VPharm is a new program that is a hybrid of the previously operating Vermont Rx assistance programs, which first started in 1989.  The wrap around features allow the state to pay enrollee out-of-pocket costs; it starts January 1, 2006.

State law(s)

2005: H 516

Eligibility

Residents on Medicare or SSDI with annual income up to 225% FPL. ($22,050 in 2006.)  For those between 150% and 225% FPL, only maintenance drugs in those classes are covered.  For those on Medicaid and those below 150% FPL, both maintenance and acute drugs are covered.  VPharm also covers most cost-sharing that is not paid by the federal Medicare Part D low-income subsidy.

Disabilities coverage

Persons with disabilities under age 65 are eligible for state benefits, including coverage during the 2-year waiting period for federal Medicare eligibility.  Must be eligible for Medicare Part A or enrolled in Medicare Part B.

Benefit example

For duals, will cover all non-part D drugs.  For pharmaceuticals-only benefit, will cover all costs of premium, copay, coinsurance and doughnut hole.  Those above dual eligible income cutoff pay on a sliding scale: 150-175% pay $13 VPharm premium; 175-200% pay $17 premium; 200-225% pay $35 premium.  VPharm pays all other costs.

Special features

VPharm Program started January 1, 2006.  Received CMS approval to do auto assignment of duals into a few commercial Part D plans.  Covers all costs (other than VPharm premium) for Rx only benefit side.  The state has additional pharmaceutical assistance programs for non-Medicare populations.

Requirements & Limits

Will not pay for brand products not covered by enrollee's PDP formulary.  VPharm enrollees must enroll in Part D and federal Extra Help if qualified to receive it.

SPAP legal status

Qualified SPAP approved by CMS; payments count toward enrollee TrOOP, 10/05.

Est. # of beneficiaries

Total = 30,000 (Rx + duals)   Rx only= 15,000.

Funding source

General funds, plus some matching funds (after clawback) for the dual population, based on a Medicaid 1115 waiver.

2006 & future issues

VHAP-Pharmacy, VScript and VScript expanded will continue only for those who are 65 and older or who receive disability benefits from Social Security, but who are not eligible for Medicare.  VPharm was created as a wraparound for Part D.
[Source: "State Part D Wrap Around for SPAP Beneficiaries," Report by the Centers for Medicare and Medicaid Services, April 5, 2006.]

Contact & information
Web site

Dir. of Health Program Integration Unit (VHAccess)
Telephone: 802-
http://www.dad.state.vt.us/MedicarePartD/Flyers.pdf
http://www.dad.state.vt.us/MedicarePartD/Default.htm

The Virginia SPAP pays Medicare Part D costs for people diagnosed with HIV/AIDS who get medicines through the Virginia AIDS Drug Assistance Program (ADAP).

State law(s)

Eligibility

Must be Medicare eligible, diagnosed with HIV/AIDS and enrolled in both ADAP and a Medicare Part D plan.  Household income between 135% and 300% Federal Poverty Level ($13,230 and $29,400 for a single person; up to $39,600 for a 2-person household in 2006)

Qualified SPAP approved by CMS; payments count toward enrollee TrOOP, 12/31/06

On February 4, Gov. Gregoire announced a new plan to use $14 million already appropriated for the "clawback" but no longer owed to HHS due a recalculation of the state's total for FY 2006.  The funds will be used as a state payment of the $1 to $5 copayments owed by dual-eligibles.  "There are a multitude of transition issues that must be dealt with; but setting those aside for the moment, it is the co-pays that serve to be the greatest barrier to this population receiving medications.  I have spoken to the Legislative leadership, they have agreed for one year to appropriate the $14 million of state money to pay for these co-pays."

State law(s)

2006 supplemental budget language passed by legislature in March as SB 6386 and signed by the Governor on March 31 reappropriates $14 million in savings savings, for the purpose of covering co-pays through the end of June, 2007 (the end of WA 2005-2007 biennial budget period).

Eligibility

Medicaid dual-eligibles under 150% of federal poverty.

SPAP legal status

Not currently certified as a qualified SPAP; state payments do not count toward enrollee TrOOP according to CMS, as of 12/06.
NOTE: see below --WA State Health Insurance PAP is a Qualified SPAP approved by CMS; payments count toward enrollee TrOOP, 12/31/06

Through 6/06, $1.722 million spent on 873,127 claims.  The Average cost/claim is $1.97.  The number of claims/person dropped from 5.68 in 2/06 to 2.96 in 6/06.  From February through June 2006, the program has not spent as much as had been anticipated.

A voluntary Medicare Part D wrap around benefit was negotiated but not agreed to in 2006.  SeniorCare Rx  does not offer any "donut-hole" coverage for those up to about 240% FPL, but does have sliding scale cost-sharing as income rises. 
NEW: The WI federal waiver, set to expire 7/1/07, has been extended to December 31, 2007, pending a state redesign.  (5/4/07)

State law(s)

Wis. Admin. Code (HFS 109);
SB 55 (2001) (Sec. 1823, 49.477);  WI Stat. § 49.688 (2004);
The program has an approved Medicaid 1115 "Pharmacy Plus" waiver, still in effect for 2006 and 2007.

Eligibility

Resident age 65 or older up to (level 1, 160% FPL), (level 2a, 200% FPL),  (level 2b, 240% FPL) receive subsidy.  If over $22,969 per individual (level 3),  the enrollee must "spend down" below that amount.  There is no asset limit.  A $30 annual enrollment fee per person is required.  Program participants are subject to certain annual out-of-pocket expense requirements depending on their annual income.
(Income levels based on the 2005 federal poverty guidelines, still in effect 1/26/06).

Disabilities coverage

Excludes the disabled, whether or not on Medicare.

Benefit example

An individual whose gross annual income is greater than 160% of the current FPL and less than or equal to 200% of the current FPL will have an annual deductible of $500, meaning participant(s) pay for the first $500 of covered prescription drug costs at participating pharmacies each year.   After the $500 deductible is met, covered prescription drugs can be purchased at the co-payment amounts for the remainder of the annual benefit period. The co-payments are $5 for each covered generic prescription drug, and $15 for each covered brand name prescription drug.

Special features

Individuals with prescription drug coverage under other health plans are eligible to enroll in SeniorCare.  If an enrollee already has a health insurance plan, SeniorCare will coordinate benefit coverage with that plan.  The Department of Health and Family Services has determined that the prescription drug coverage offered by SeniorCare is "creditable coverage." This means that SeniorCare coverage, on average, is as good as the standard Medicare drug coverage.

"Non-risk based lump sum approach.  Those in spend down are not eligible for the wraparound benefit; will not cover drugs not already covered by Part D or drugs not included in PDP formulary."
[Source: "State Part D Wrap Around for SPAP Beneficiaries," Report by the Centers for Medicare and Medicaid Services, April 5, 2006.]

Requirements & Limits

Individuals who do not re-enroll in SeniorCare when their SeniorCare prescription drug coverage ends and do not enroll in a Medicare prescription drug plan, may pay more to enroll in a Medicare prescription drug plan later. This means that if, after May 15, 2006, individuals go 63 days or longer without prescription drug coverage that is at least as good as Medicare’s prescription drug coverage, their monthly premium for a Medicare prescription drug plan will go up at least 1% per month that they did not have coverage.

SPAP legal status

Qualified SPAP for enrollees above 200% FPL; operated as a Medicaid Pharmacy Plus waiver for enrollees up to 200% FPL.

Est. # of beneficiaries 

111,267 enrolled, as of 7/16/06 (includes 79,523 waiver and 31,744 non-waiver enrollees)

Funding source

Funded through state general purpose revenue, manufacturer rebates, federal funds under the Pharmacy Plus waiver and participant cost sharing.

2006 & future issues

The program will continue until at least 6/30/07 under the current 5-year Pharmacy Plus waiver, which provides 50% matching federal funds.  A voluntary Medicare Part D wrap around benefit was slated to be developed in 2006; 2007 state legislative action is likely to resolve issues related to the federal Pharmacy Plus waiver, with an expiration date of 7/1/2007.
"State's seniors, lawmakers fight uphill battle for drug program" - news article 3/23/07 

Contact & information
Web site

SeniorCare Customer Service Hotline:  (800) 657-2038

Wyoming's pharmaceutical coverage of Medicare Part D eligibles will discontinue after May 31, 2006.  State-only coverage will continue for those under 100% FPL not qualified for Medicare.

State law(s)

Wyo. Stat §42-4-118

Eligibility

Any resident with annual income up to 100% FPL with no other Rx coverage (includes Medicare Part D).  Also has a cash asset maximum limit of $2,500.  No age restriction.  Medicare Part D enrollees will be disqualified as of June 1, 2006.

Disabilities coverage

The state will continue to include persons with disabilities with the same income and asset requirement as others.

Benefit example

The state program will cover up to three prescriptions per month, requiring enrollee copay of $25 brand, or $10 generic products. 

Special features

Also covers prescribed oxygen.

Requirements & Limits

Wyoming resident, with less than $2,500 in cash assets. (One car and one house excluded from asset calculation.)

SPAP legal status

Qualified SPAP approved by CMS; payments count toward enrollee TrOOP, 11/05.

Est. # of beneficiaries 

269 enrollees, as of 8/1/06.  The number of enrollees will likely increase; no good estimate at this time, since the program just reopened on 7/1/06.

Funding source

100% general funds.

2006 & future issues

Agency officials are "waiting to see what legislature will do with the program, since it currently has a capped enrollment."

As of 7/1/06, the program reopened to new enrollment for people earning less than the federal poverty level.  The program is not limited to only seniors or the disabled. 

Contact & information
Web site

Prescription Assistance Program
Pharmacist Consultant - Telephone 307-777-8699.
http://wdh.state.wy.us/pharmacy/pdap.asp

California's GHPP pays for medical care for individuals diagnosed as Genetically Handicapped, only n case of loss of private health insurance or Medi-Cal due to change in employment status or income.  GHPP often pays for services not fully covered by other plans.  GHPP is not providing a "wrap around" benefit for Part D, but will continue to cover excluded categories of drugs like benzodiazepines, over-the-counter medications, cough and cold agents, and barbiturates.

State law(s)

Cal. Health and Safety Code, §§ 125125 et seq. (2004).

Eligibility

Resident with a GHPP-eligible condition who is at least 21 years of age.  Recipients may be required to apply with Medi-Cal.  There are no maximum income eligibility requirements, but families with adjusted gross income (AGI) exceeding 200 percent of the federal income guidelines pay an enrollment fee and treatment costs based on a sliding fee scale for family size and income.

Disabilities coverage

GHPP provides health coverage for Californians 21 years of age and older who have specific genetic diseases including cystic fibrosis, hemophilia, sickle cell disease, and certain neurological and metabolic diseases. GHPP also serves children under the age of 21 with GHPP-eligible medical conditions who are not financially eligible for CCS.

Benefit example

GHPP only pays when a particular service is not covered by any other insurance plan a recipient may have.  GHPP is a state funded program that coordinates care and helps pay for medical costs.  

Special features

GHPP program benefits include prescription drugs, as well as blood products and oxygen, medical supplies, food supplements, medical and dental services, certain home health care services, prosthetics, psychosocial services, physical therapy, and hospital services.  GHPP is considered a payer of last resort, so clients who have other insurance must use that first.

Requirements & Limits

Individuals must have one of the qualifying genetic conditions to receive benefits.  GHPP benefit recipients may be required to apply to Medi-Cal.  The annual enrollment fee schedule shall be a sliding scale based upon family size and income and will reflect changes in the federal poverty level.  Payment of the enrollment fee is a condition of program participation, but can be waived under certain circumstances.  Clients must reapply to the program annually.

SPAP legal status

Qualified SPAP approved by CMS; payments count toward enrollee TrOOP, 10/05

Est. # of beneficiaries

Approx. 1600 patients enrolled in the program as of 12/05.

Funding source

Services for GHPP clients who are not Medi-Cal beneficiaries are paid for through the State's general fund.  AB 816, chaptered on 7/12/94 (as Ch. 195, §53(n))

2006 & future issues

The GHPP program will continue in 2006.  In 2006, everyone who is enrolled in Medicare Part D will no longer have prescription drug coverage through GHPP.  The GHPP will cover medically necessary drugs that are specifically excluded from the Medicare Part D plan in which the GHPP client is enrolled.  GHPP is considered creditable coverage, so GHPP clients are not required to enroll in Part D and will not be penalized for enrolling beyond the deadline (as long as GHPP coverage is kept current).

Contact & information
Web site

The program is administered statewide through the GHPP office in Sacramento
(1-800-639-0597 or 916-327-0470)
http://www.dhs.ca.gov/pcfh/cms/ghpp/ http://www.dhs.ca.gov/pcfh/cms/ghpp/pdf/ghppbrochure.pdf

This statewide High Risk Pool was not designed as a pharmaceutical assistance program, but for 2006 it became the second to gain CMS approval as a qualified SPAP.  The FCHA will cover 100 percent of the Medicare-eligible enrollee's share of costs.   All enrollees must pay a substantial pool insurance premium.

State law(s)

1983, 1989

Eligibility

Florida's high-risk pool, the Florida Comprehensive Health Association has been closed to new enrollment since 1991. Only for people who are rejected as uninsurable for Medicare supplemental insurance coverage.  

Disabilities coverage

Covers people with AIDS, End State Renal Disease (ESRD) as examples.

Benefit example

Cost-sharing: $1000 deductible, 80/90% coinsurance. Once FCHA premiums and deductibles are paid, the state program will cover 100 percent of the Medicare-eligible enrollee's share of costs. Comprehensive coverage includes RX, major medical and specific disease care.

Special features

High risk pool product only.  This program was the second such non-pharmacy specific program (after Washington) approved by CMS as a qualified SPAP, although not necessarily fitting the typical state SPAP design..

Requirements & Limits

Substantial annual premiums are required for enrollees. Example: A 53-year old male pays $4,386  The premium structure:  200% maximum for low-risk; 225% maximum for medium-risk; 250% maximum for high-risk. Each insured's risk class is determined by his/her medical condition, history, and anticipated claims costs.

SPAP legal status

Qualified SPAP approved by CMS; payments count toward enrollee TrOOP, 12/21/05.

Est. # of beneficiaries

There are approximately 500 individual who remain enrolled in the program.

Funding source

Premiums

2006 & future issues

Contact & information
Web site

The MD Kidney Disease Program will cover Medicare Part D deductibles, copayments or coinsurance, and purchases during the coverage gap.  The program traditionally was not considered an "SPAP," especially since the state had two separate SPAPs aimed at seniors or low-income residents.  However, the program was certified by CMS in November 2005 as a qualified SPAP.

State law(s)

Md. Ann. Code §10.20.01 (founded in 1971)

Eligibility

Must be a Maryland resident, eligible and enrolled in Medicare parts A and B, and a kidney transplant or dialysis patient with end stage renal disease (ESRD), as certified by a physician.  There is no maximum income cutoff; enrollees above 175% or 200% FPL pay a program participation fee or premium to join.  There are no age restrictions.  Lawfully admitted permanent resident aliens are eligible.

Disabilities coverage

End stage renal disease (ESRD) patients only. 

Benefit example

Payer of last resort (after Medicare A/B/D, insurance, etc.) as long as product or service is on the kidney disease program’s formulary.  The program will pay deductibles, copayments or coinsurance, and purchases during the coverage gap.

Special features

Program pays for services, MD visits, Rx and OTCs on formulary, in-patient related items as well.

Requirements & Limits

Must apply for Medicare (but not necessarily part D.). Must notify the program of all "payment received from any source" related to ESRD treatment.  Annual recertification is required.

SPAP legal status

Qualified SPAP approved by CMS; payments count toward enrollee TrOOP, 10/05.

Est. # of beneficiaries

2,550 total currently in the program. The state had not calculated how many will get assistance from the Part D wrap around specifically, as of 12/15/05.

Funding source

100% state funds, general fund.

2006 & future issues

Right now patients are not required to purchase Part D PDP, but that might change. Regulations also would have to be changed.

Contact & information
Web site

Kidney Disease Program
Telephone (410) 767-5000
No specific website.  Use CMS for Medicare info.

Texas does not have a broad senior pharmaceutical assistance program in operation in 2005-2006.
Beginning 1/1/06, Kidney Health Care (KHC) and Mental Health Medication Program recipients will receive drug coverage through Medicare Rx, the new Medicare prescription drug program.  KHC will not become part of Medicare Rx, but KHC will be coordinating new prescription drug benefits for its program recipients.  The KHC program will provide wrap around benefits for Medicare Part D premiums, deductibles, and co-insurances, above the subsidized amounts for KHC program recipients, for drugs on the KHC formulary and the plan formularies.

State law(s)

Tex. Health & Safety Code Ann., Title II, Ch. 42 ;
Kidney Health Care Act,; H 494 (1999)

Eligibility

Residents with diagnosis of End Stage Renal Disease (ESRD), with annual income less than 135% FPL ($17,820 for a family of 2 may receive full subsidy; with an income of $17,821 to $19,800 for a family of 2 may receive partial subsidy (up to 150% FPL for 2006).

Disabilities coverage

Any full dual eligible individual living in an institution will not have to make co-payments.  Mentally disabled individuals who are enrolled in the ICF/MR program are in an "institution" for the purposes of Medicare Rx.  Any partial dual eligible individual living in an institution will have to pay co-payments of $1-5.

Benefit example

KHC provides limited assistance for Medicare Rx costs for premiums, deductibles, co-insurances and gap coverage.

Special features

The plan will cover Medicare Rx excluded drugs that are on the KHC formulary (vitamins and OTC drugs).  Drug assistance is limited to 4 prescriptions per month and they must be on the KHC formulary ($6 co-payment may apply).

Requirements & Limits

Anyone eligible for Medicare must enroll in Medicare Rx plan, since KHC drug coverage will end on 3/31/06. Not available to recipients with private drug coverage or who are enrolled in Medicare Advantage plan.

SPAP legal status

Qualified SPAP approved by CMS; payments count toward enrollee TrOOP, 10/05.

Est. # of beneficiaries

24,239 eligible recipients (as of FY 2004).
12,299 eligible for drug benefits (as of FY 2004)

Funding source

State funds and resources

2006 & future issues

KHC recipients have until 3/31/06 to enroll in a prescription drug plan.

Contact & information
Web site

Kidney Health Care Program
General Information: (512) 458-7150 or 1-800-222-3986
www.dshs.state.tx.us/kidney/default.shtm
http://www.texasmedicarerx.com/
kidneynet@dshs.state.tx.us

This statewide High Risk Pool was not designed as a pharmaceutical assistance program, but for 2006 it became the first to gain CMS approval as a qualified SPAP.  The Pool will cover 100 percent of the Medicare-eligible enrollee's share of costs and 80 percent of products not covered by Medicare.   All enrollees must pay a substantial Pool insurance premium.

State law(s)

Wash. Rev. Code §48.41.  High risk pool was established in 1988.

Eligibility

Only for people who are rejected as uninsurable for Medicare supplemental insurance coverage.  Also must be in the WSHIP as of 11/20/05 and a sign up for a Medicare Part D plan. 

Disabilities coverage

Includes people with AIDS, ESRD as examples.

Benefit example

The new product, which is still under Insurance Commissioner’s review, will cover 100% of any balance that Medicare covers, and 80% of anything (Rx or service) that Medicare does not cover.

Special features

High risk pool product only.  This program was the first such non-pharmacy specific program approved by CMS as a qualified SPAP, although not necessarily fitting the typical state SPAP design..

Requirements & Limits

Enrollees pay Part B and D premiums themselves.

SPAP legal status

Qualified SPAP approved by CMS; payments count toward enrollee TrOOP, 10/05.

Est. # of beneficiaries

1000 are eligible to choose this, which they probably will since it will be a less expensive option to what they currently have as a Medicare product.

Funding source

The state’s contribution is collected from assessments to the high risk pool insurance carriers.  That tax collection is then passed to the state, which then pays the non-profit entity (created by statute) to cover the losses.

2006 & future issues

Congress may support more High Risk Pools with funding, and if they do, then the SPAP portion will be separated from the HRP portion so they can get the federal funds.  (Generally SPAPs cannot obtain federal funds, except through 1115 Pharmacy Plus waivers.)

Contact & information
Web site

WSHIP  
Telephone: 360-766-6336
http://www.wship.org/