State Medicare Part D Transitional and Emergency Coverage
Updated: May 12, 2006
Reposted: December, 2006
| In response to start-up problems with the new Medicare Part D program, a rapidly growing number of states have decided to temporarily cover prescription drugs for dual-eligibles and other Medicare enrollees. Most problems are related to Prescription Drug Plan (PDP) enrollment records, coverage records not available at the pharmacy point of sale or charging excess copayments to enrollees entitled to the low income subsidy or "extra help." |
 |
This table summarizes actions in 37 states and DC, implemented in January and February 2006 on an emergency or transitional basis, to assist those who are legally entitled to benefits, but have difficulty receiving them. As of March 15, 44 states had made some type of payment for which they planned to seek federal program reimbursement. 26 states acted before the announcement on January 24 of a federal plan to reimburse state expenditures or guarantees. Some states enacted laws authorizing the actions, including California, Connecticut, Massachusetts, New Hampshire, New York, North Dakota and Vermont. The New York's measure became law by veto override on February 7. Others used state executive authority through their Medicaid agencies. Most states have focused on the Medicaid-Medicare dual-eligible population, but several are providing special transitional assistance to enrollees in state pharmaceutical assistance programs. Most state plans described below assume that the state will be reimbursed by the PDP plans using federal funds; some states already appropriated or designated state funds for temporary use.
On January 24 the Centers for Medicare & Medicaid Services (CMS) launched a new state reimbursement plan to "enable states to be fully reimbursed for their efforts to help ensure that their beneficiaries eligible for Medicare and Medicaid have access to their covered Medicare drugs as they move to their new Medicare Part D drug coverage." Defined as a waiver demonstration, the plan also supports limiting the need for state reimbursement by supporting the use of Medicare payment systems whenever possible, and promotes the effective transition of dually eligible Medicare beneficiaries into their new Medicare coverage. It will be in effect through February 15. Secretary Levitt reported on February 22 that "The reimbursement program for administrative payments and limited drug payments will continue as needed for the coming weeks." A CMS template (online) was published February 2 for use by states who have reinstituted some coverage through their Medicaid programs for dual eligibles. CMS plans to work with affected states to develop a process for reconciling payments involving beneficiaries in State Pharmacy Assistance Programs (SPAPs) enrolled in Medicare Part D.
NCSL description: State Reimbursement for Medicare Part D Transition - posted 1/25/06
In a related development, CMS released revised "clawback" state figures on February 6, 2006 that show states will owe $706 million less than announced in 2005. See CMS Administrator Mark McClellan Announces Clawback Reduction.
A week earlier, Health and Human Services (HHS) officials outlined a variety of steps to end interruptions that have occurred in access to medications by the poor. They also clarified that it is up to drug plans to ensure that states are properly paid for restarting Medicaid drug coverage in some cases. Key recent notices and guidelines from the Centers for Medicare and Medicaid Services (CMS) are posted on the NCSL website at http://www.ncsl.org/programs/health/MedicareRx.htm.
A Kaiser Commission report released February 28 with results of a survey of Medicaid Directors notes, "The most common problems included incorrect cost-sharing charged to beneficiaries (49 states), pharmacies could not bill plans (44 states), and beneficiaries were unable to obtain non-formulary drug (43 states)."4
A separate NCSL SPAP Part D report details 20+ states providing more permanent "wrap around" or supplemental state coverage through state pharmaceutical assistance programs (SPAPs) for 2006 and beyond.
| State |
Coverage |
Explanation / legal authority (laws in bold)/ dates |
| Alabama |
Loans to pharmacies |
State will loan pharmacies funds to cover the costs of the prescriptions until the Medicare payment can be adjudicated. 1 Governor's Announcement, 1/13/06 |
| Alaska |
Dual-eligibles |
State covers one 30-day transitional supply. Terminates on 3/31/06. 2 |
| Arizona |
Dual-eligibles |
State covering people that have had organ transplants, have life threatening conditions or haven't been assigned to a Part D Plan.
Executive Order 1, promulgated 1/13/06. |
| Arkansas |
Dual-eligibles |
Executive authority declared public health emergency. News article 1/24/06. On 2/15 the emergency program was extended through March 17. As of 2/15/06 the state so far has spent more than $4.8 million to provide drugs to 21,000 dual eligibles, but the number of requests from pharmacies for reimbursement is declining. |
| California |
Dual-eligibles |
Executive authority allows state to cover prescriptions when Medicare payment cannot be adjudicated, from 1/12/06 to 1/17/06.
2006 emergency law, AB 132, appropriates $150 million for use through 2/11/06; signed by governor 1/20/06. Governor's release online | Governor's speech online. |
| Connecticut |
Dual-eligibles and ConnPACE (SPAP) enrollees |
State covers prescriptions when Medicare payment cannot be adjudicated.
2005 law signed 12/1/05, SB 2500. 2 |
| Delaware |
|
On 2/15/06 the Medicare Rights Center reported a state-initiated coverage effort; details not available online as of 2/16/06. |
| Florida |
Dual-cases Covereligibles |
State covers prescriptions when Medicare payment cannot be adjudicated. Governor's Executive Order 06-24, began 1/26/06, after federal reimbursement was announced; to expire 2/15/06 unless extended. |
| Georgia |
|
Plan reported by Kaiser Commission/HMA 2/06 but no details published. 4 |
| Hawaii |
Dual-eligibles |
State covers prescriptions when Medicare payment cannot be adjudicated. 2 |
| Idaho |
Individual dual-eligible cases |
Cover cost of "critical drugs" on a case by case analysis. 3
Dept of Health & Welfare pharmacy policy |
| Illinois |
Dual-eligibles and Illinois Cares Rx (SPAP) enrollees |
Executive authority allows state to cover Part D approved prescriptions when Medicare payment cannot be adjudicated. Governor's Announcement, 1/12/06. 2 |
| Kansas |
Dual-eligibles |
State covers Part D approved prescriptions when Medicare payment cannot be adjudicated. Terminates on 2/1/06. 1, 2 |
| Maine |
Dual-eligibles and
SPAP enrollees |
State covers copayments above those set by CMS. Began 1/3/06. 2 |
| Maryland |
Dual-eligibles |
State covers Part D approved prescriptions when Medicare payment cannot be adjudicated. Also provided an "early fill" policy in December -"As a result of this effort, approximately 38,000 prescriptions to 15,000 Medicaid recipients were filled."
Governor's announcement, 2/1/06 | News article: 90 Rx paid during 1/06. |
| Massachusetts |
Dual-eligibles |
2005 law allows state to cover non-Part D out-patient prescriptions and cover excess copayment. Chapter 175 of 2005 signed into law 12/30/05. Began 1/7/06. 2 |
| Minnesota |
Dual-eligibles |
State covers prescriptions when Medicare payment cannot be adjudicated. Governor's Council Resolution, 1/18/06; effective through 2/17/06. 2 The state has asked the federal government to reimburse it for costs incurred after Feb. 15, and Gov. Pawlenty said he feels assured the waiver will be granted. Legislative approval is required for coverage beyond 2/17; they reconvene on 3/1/06. |
| Missouri |
Dual-eligibles |
State covers prescriptions when Medicare payment cannot be adjudicated. Began 1/17/06. Department of Social Services announcement. |
| Montana |
Dual-eligibles |
State "will pay for erroneous deductibles and high co-pays charged to full benefit dual eligible clients. This payment will remain in place until the issue can be resolved with the client’s PDP. Agency policy online, effective 1/13/06, until resolved. |
| Nevada |
|
Plan reported by Kaiser Commission/HMA, with state payments "under $100,000" 2/06 but no other details published. 4 |
| New Hampshire |
Dual-eligibles |
State covers prescriptions when Medicare payment cannot be adjudicated from 1/10/06 until 3/1/06. Executive Order 2006-01 and law, SB 393, enacted 1/10/06 includes appropriation of $500,000. |
| New Jersey |
Dual-eligibles |
State covers prescriptions when Medicare payment cannot be adjudicated. 1/6/06. 1 |
| New Mexico |
Dual-eligibles |
Reported as 850 duals receiving 1700 prescriptions, with payments of $76,000 covering a 5-week period. |
| New York |
Dual-eligibles |
Governor: allowed temporary administrative edit for 2 weeks.
2006 emergency law, A 9462, to pay pharmacists, retroactive from 1/1/06 until "no longer necessary."
A 9554 enacted 4/12/06 would set daedline for 1/14/07; vetoed and overridden; in court)
(Passed legislature; vetoed by Governor, veto overridden to become law, 2/7/06) |
| North Dakota |
Dual-eligibles and
Part D enrollees |
State covers prescriptions when Medicare payment cannot be adjudicated or when Medicare enrollee has not received their plan information between 1/6/06 and 1/23/06. State may provide additional help on a case-by-case basis until 2/15/06.
2005 law HB 1465, signed 4/25/05. |
| Ohio |
Dual-eligibles |
Executive action allows state to pay excess copayments from Part D plans from 1/13/06 until 1/31/06. Policy may be extended "if further assistance is necessary."
Governor's announcement, 1/13/06. |
| Oregon |
Dual-eligibles |
State covers prescription costs when Medicare payment cannot be adjudicated.
Governor's announcement, 1/13/06. |
| Pennsylvania |
Dual-eligibles |
Executive action allows state Medicaid to pay the excess copay, the amount individuals are inappropriately charged over the low-income subsidy level. State expects to spend no more than $2 million during January and expects to be reimbursed by CMS and the plans for the costs. Governor's announcement, 1/12/06.
Online: Pharmacy Cost Sharing Instructions (Interim) |
| Rhode Island |
Dual-eligibles |
Executive action allows pharmacies to bill state if claim cannot be adjudicated with Medicare from 1/11/06 until 3/2/06. Executive Order 06-03 extending date, 1/30/06 | Governor's announcement, 1/11/06 |
| South Dakota |
Dual-eligibles |
Executive action allows for a 30-day prescription from 1/9/06 until 2/15/06.
Deadline extended announcement, 1/27/06 | Governor's announcement, 1/9/06. |
| Tennessee |
Dual-eligibles |
Plan reported by Kaiser Commission/HMA 2/06 but no other details published. 4 |
| Texas |
Dual-eligibles |
Executive action announced 1/25/06 authorizes Texas Health and Human Services Commission to cover Part D approved prescriptions when Medicare payment cannot be adjudicated. Established after federal reimbursement was announced.
Health and Human Services Commission announcement, 1/25/06 |
| Utah |
Dual-eligibles |
Executive action allows for state to pay for 30 days supplies. The program ended after expending $909,000. See story online | March 15 update |
| Vermont |
Dual-eligibles and SPAP enrollees |
2006 emergency law; covering all uncovered charges for enrollees until 3/1/06 or "until federal operational problems cease." H 582 signed 1/10/06. Date extended to 3/1/06 on 2/1/06. See story online. | Vermont to reactivate federal drug plan March 8 published by Rutland Herald 2/23/06 |
| Virginia |
Dual-eligibles |
Executive action allows state to cover prescription costs when Medicare payment cannot be adjudicated. Emergency coverage "will end within the next few weeks once Part D implementation problems have been resolved." Executive announcement, 1/31/06 |
| Washington |
Dual-eligibles |
Plan reported by Kaiser Commission/HMA 2/06 . The state continued to pay Part D covered drugs for institutionalized dual-eligibles. As of 2/21/06, the state began paying dual eligible copays. 4 |
| Wisconsin |
Dual-eligibles |
Executive action allows state to cover one-time prescription costs when Medicare payment cannot be adjudicated. Began 1/13/06. Governor's announcement online, 1/13/06. |
| District of Columbia |
Dual-eligibles |
State covers prescription costs when billing Medicare PDP is unsuccessful. Mayor's announcement; began 1/18/06, will terminate in 90 days on 4/17/06. 2 |
| |
Total = 37 states
+ D.C. |
|
Sources: NCSL survey and state research, January to March 2006.
1 - National Association of State Medicaid Directors (NASMD) www.nasmd.org
2 - National Association of Chain Drug Stores (NACDS)
http://www.nacds.org/user-assets/pdfs/gov_affairs/medresource/StatePartDTransitionalCoverageChart.pdf
and National Legislative Association on Prescription Drug Prices (NLARx) www.nlarx.org
3 - Health Assistance Partnership www.healthassistancepartnership.org
4 - Kaiser Commission on Medicaid and the Uninsured, "The Transition of Dual Eligibles to Medicare Part D Prescription Drug Coverage: State Actions During Implementation", February 2006. http://www.kff.org/medicaid/upload/7467.pdf
Kaiser Chart: Medicare Beneficiaries with Creditable Prescription Drug Coverage by Type, as of April 18, 2006
Related Resources:
Nearly 24 Million Medicare Beneficiaries Now Have Prescription Drug Coverage - HHS news release 1/17/2006.
Arkansas: Drug plan bailout at $2.7 million so far - 1/24/2006.
Using this report: The information listed is the best known and available from multiple sources as of the date noted. It is designed as a tracking report, subject to regular additions. Disclaimer: This report includes brief summaries of state actions and is not intended as an offer of consumer benefits. States may have additional terms and conditions not described in this summary. Please use the links included in the table above for further information.
Also see NCSL's State Pharmaceutical Assistance Programs in 2006: Helping to Make Medicare Part D Easier and More Affordable.
For latest updates revisit this report at: http://www.ncsl.org/programs/health/PartDPatch.htm
Back to Pharmaceuticals | Health Menu Page
|
