• Mission & Governance
• Services Overview
• How to Get Involved
• Standing Committees
• NCSL Foundation

• Issue Areas: A-Z
• State-Federal Relations
• NCSL Standing Committees
• News from D.C. and the States

• About State Legislatures
• Elections, Campaigns & Redistricting
• NCSL's StateConnect Directory
• Web Sites

• Online Guide to NCSL Services
• Staff Sections and Networks
• Meetings & Professional Development
• Staff Directories

• Meetings Calendar
• Online Registration
• Meetings Home Page
• Legislative Summit

• Bookstore
• State Legislatures Magazine
• NCSL's StateConnect Directory

Summary Table of Wrap Around Plans

Emergency Gap Plans

State SPAP Details (below)  SPAP Report (11/07)

Rx & SPAP Definitions

Many state governments play a substantial role in offering direct pharmaceutical assistance benefits to eligible residents.  Most commonly, individual states have offered substantial subsidies to low and moderate income seniors.  About half the states include younger adults with disabilities among those eligible.  

A majority of these programs are recognized within the federal Medicare Modernization Act (MMA) and are termed State Pharmaceutical Assistance Programs or "SPAPs" in the federal law.^{1, 2}  In the past five years, a growing number of states also offer state pharmaceutical discount programs.  After 20 plus years of evolution and expansion, state pharmaceutical subsidies reach an estimated 1.8 million enrollees, while state discount programs are offered to another 5.5 million residents nationwide as of mid-2007.

From the state perspective, the passage of the MMA in December 2003 presented important opportunities and benefits as well as challenges and options.  The legal structure of the Medicare Modernization Act, with its emphasis on voluntary enrollment, means there is extraordinary opportunity for state flexibility in connecting the state’s voluntary programs to the new federal program.

This report analyzes the diverse steps taken by individual states to adjust existing subsidy programs to better fit with the Part D Medicare prescription drug benefits that became available on January 1, 2006.   It also includes programs newly created in 2005-06 that are designed to coordinate with Part D benefits.  More than 1.5 million beneficiaries will be eligible for these state subsidies in at least 20 states.  In broad terms, the legislative actions taken so far seek to combine or select among several goals:

1. Providing state funds to enhance or supplement Medicare Part D prescription drug coverage for selected state residents, a strategy commonly termed "wrap around benefits."  For example, New York's EPIC program is paying for yearly deductibles (between $0-$265 in 2007), co-insurance or copayments, the gap in coverage above $2,400 (in 2007) and pharmaceuticals not covered by Medicare.  At least 16 states committed to this approach, most beginning January 1, 2006.  In addition, six states enacted first-time subsidy programs that focus entirely on wrap around or supplementing MMA benefits: Alaska, Hawaii, Kentucky, Montana, New Hampshire and Washington.  Not all programs are operational.   The financial numbers for 2007 and 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)

1. Emergency transition or "gap coverage" for dually-eligible enrollees who are denied service at pharmacies due to record-keeping flaws or other eligibility processing issues.  In quick response to problems at pharmacy counters, at least 37 states created temporary authorization to cover claims that should be eligible for Medicare payment eventually.  These states include Alabama, Alaska, Arizona, Arkansas, California, Connecticut, District of Columbia, Hawaii, Idaho, Illinois, Kansas, Maine, Massachusetts, Minnesota, Missouri, Montana, New Hampshire, New Jersey, New York, North Dakota, Ohio, Oregon, Pennsylvania, Rhode Island, South Dakota, Utah, Vermont and Wisconsin which acted prior to the federal announcement of state reimbursement.  By April at least 11 additional states joined after the HHS announcement.  The actual state role varies considerably.  Online: Emergency Gap Plans, 2006.
2. Redirecting some state-funded pharmaceutical program services to populations not covered by Medicare. Examples of newly enacted Rx plans aimed at under-65 adults or families include Arkansas, Illinois, Maryland, Montana, New Mexico and Oklahoma.⁴
3. Reducing or eliminating benefits previously included in state SPAP programs that will now be covered by Medicare Part D.  Almost all programs reduced or eliminated those 2005 state benefits that are now fully available through the federal program. Most enrollees did not see their coverage reduced as a result.  For example, as of January 1, Part D beneficiaries in the lowest-income tier (under 135 percent of federal poverty or $12,919 annually for '06) have no premiums or coverage gaps.  In other examples, Missouri requires state enrollees over 150 percent to use Part D instead of the state program; Wyoming dropped Medicare eligibles as of June 2006 and continues coverage for those not allowed in Medicare. Delaware requires Part D enrollment in order to receive a state subsidy, while the effective date for being in a Part D plan was pushed back to March 31, 2006.
4. Terminating the state-funded program.  Five states elected the termination approach, including Florida, Kansas, Michigan, Minnesota, and North Carolina, generally because the state-only program offered benefits very similar to the 2006 Medicare choices.  The North Carolina program restarted in January 2007.

State Timetables:  The two-year implementation period (between passage of the law in December 8, 2003 and January 1, 2006) provided a relatively short time for state legislatures and executives to change and update their state programs.  In 2004, quite a few states moved quickly to work with the temporary Medicare Discount Card program.  Several states initiated the idea of automatic enrollment of state beneficiaries into Medicare Discount Cards with state benefits coordinating with the federal discount, and ultimately reported substantial success in signing up Medicare-eligible residents.  However, in 2004, prior to federal rule-making affecting many aspects of Part D implementation, it was not possible for individual states to design and enact more permanent coordination plans focused on benefits that would begin in 2006. 

In most states, active planning and legislative activity began when the federal Final Regulations, promulgated on January 26, 2005, provided a firm legal basis for redesigning or initiating state pharmaceutical programs.  With 32 states scheduled to meet and complete legislative sessions before July 1, 2005, most legislatures had only three to five months to consider and act on SPAP changes.  While recognizing that Medicare enrollees were not compelled to enroll in Part D but instead would choose to enroll or not, an extraordinary number of states chose to enact laws coordinating their programs with the Medicare Program-- at least 28 states by one definition. ⁵  

Wrap around and Coordinated Benefits: The most notable SPAP changes are so-called “wrap around” benefits.  Generally this approach allows for combining a set of federally-funded benefits with another package of state-funded benefits, enabling the enrollee to pay lower out-of-pocket charges for prescriptions than with the federal program alone, or to receive a type of drug not available through Medicare.  The Part D benefit design is complex and MMA allows for variability among Medicare Part D drug plans.  Even before specific drug plans were approved by the federal government, states assessed which “wrap around” features would be most important or desirable.  Virtually all of the 2005 state laws detailed in this report were enacted before the PDP's unveiled their plan designs, formularies, or premium structures.⁷ 

1. Use state resources to pay part or all of the annual deductible for selected Medicare beneficiaries ($275 in 2008; was $250 in 2006); 
2. Use state resources to pay part or all of the Part D monthly premium (estimated to average $25 per month in '08) for selected Medicare beneficiaries;
3. Use state resources to pay part of the patient per-transaction copayment or coinsurance for selected Medicare beneficiaries;
4. Use state resources to pay part of or the entire coverage gap ("doughnut hole"), from $2,510 to $5,726.25 in 2008, for selected Medicare beneficiaries;
5. Cover pharmaceutical products excluded from coverage by Medicare Part D or not included in formularies of individual Part D plans. The Medicare Excluded Drug Categories are fertility, weight loss, cosmetic, birth control, barbiturates, benzodiazepines, hair growth, vitamins and Over-the-Counter products;
6. Require enrollment in Part D as a condition of receiving state benefits, or authorize voluntary automatic enrollment into locally available Part D plans.

As noted above, least five states without state-funded programs at the end of 2003 created new SPAP-style programs in 2005, with fairly similar goals or features.  Separately, at least six states launched pharmaceutical programs for non-Medicare populations.  These are described in a separate NCSL report.

The 2007 Federal Poverty Guidelines, released January 24, 2007, were established as $10,210 annual income for an individual and $13,690 for a two-person household.  These figures reflect an increase of about 4.2 percent over the 2006 guidelines.  Some figures listed in the tables below use 2006 figures, still in place in some state programs.

How to Use this Report The November 2006 edition of this report is an updated work-in-progress.  Much of the information provided is based on laws enacted in 2005-06, and includes some provisions not yet implemented as of the completion of research on this report.  Some features authorized by state law may not be available or implemented for 2006.  Individual state descriptions reflect the best available information as of the dates noted, and are intended for comparative use by policymakers, researchers and others involved in state-level activities.     Medicare Enrollees: Individuals eligible for Medicare and others are welcome to read and use this report for general information.  Please use the state-level charts at "State," with web links and telephone numbers included below for additional help in understanding specific state assistance, including application forms and telephone helplines.  Many state programs have additional terms and conditions not described in the brief summaries listed below. Information will be expanded in future editions; please revisit the online edition for the latest material.    Disclaimer:  This report is not intended as an official consumer guide or an offer of state-funded services.  NCSL is not responsible for the availability or unavailability of benefits to individual residents, or for information contained on third-party web pages.

Map of State SPAP Programs

 

A closer look at two states (in Table 1) serves as an example of the various components of state approaches.

TABLE 1 – Examples of Coordinated benefits for an individual over 150% of FPL³ (over $15,315 for 2007) 

This table uses Illinois and Nevada as illustrative examples of wrap around benefits.  Details for other features and other states are provided in part 2 of this report.

STATE OPTIONS AND CHALLENGES

The 2007 Federal Poverty Guidelines, released January 24, 2007, are established as $10,210 annual income for an individual and $13,690 for a two-person household. These figures reflect an increase of about 4.2 percent over the 2006 guidelines. Alaska and Hawaii have higher levels.  Some figures listed in the tables below use 2006 figures, still in place in some state programs.  Most, but not all, states rely on these figures for eligibility and benefits. 

Coverage for Non-Elderly Persons with Disabilities.   For a number of years, some state-only Rx programs included some non-elderly adults with disabilities—that is, non-elderly persons who qualify for Social Security Disability Insurance (SSDI)—while others covered elders only.   The MMA Part D benefit is linked to eligibility for Medicare and, for younger persons on SSDI, is available only after a beneficiary has met a two-year waiting period for Medicare eligibility. This presents special challenges to states where eligibility for state pharmaceutical benefits is acquired sooner through eligibility for SSDI alone.  Several states (CT, DE, IL, ME, MD, MA, NV, NJ, RI, VT) will continue to use the broader definition—eligibility for SSDI—for state pharmaceutical benefits.  [List updated 2/10/06.]

Residence, Citizenship and Alien Status.  Some existing state pharmaceutical programs do not require the same standard of documented status for non-citizens as Medicare.  Low-income state residents who are ineligible for Medicare due to citizenship or alien status require special attention in redesigned state programs to specify their eligibility status for state-only benefits in 2006 and beyond.  For example, states like Illinois specify that such residents are eligible; in Missouri they will be ineligible; in Alaska they could get a non-federal pharmaceutical plan wrap around benefit.   The new, higher standard of proof of citizenship for Medicaid, effective July 1, 2006 also may have an effect of shifting some enrollees to state-only programs.

Changing Income Levels of Enrollees. Virtually all state programs include specific income eligibility maximums, such as 175% or 200% of the federal poverty guidelines, often termed the “FPL.”  The federal Part D benefit is available to all Medicare beneficiaries with no income limit but offers additional financial assistance to persons with incomes under 150% of FPL.  State SPAP enrollees at or close to an income maximum may face complex situations if their monthly or annual income changes by a few dollars.  They might lose wrap around benefits in mid-year if so defined in state law, or lose federal extra help while remaining in a state program and even be able to receive a higher amount from their state.  NOTE: On January 24, 2006 the 2006 poverty guidelines were released, providing about a 2.4 percent increase for individuals compared to 2005.

Medicaid Program Changes.  All 50 state Medicaid programs had to adjust to the transfer of dual-eligible Medicare-Medicaid enrollees to Medicare coverage, meaning Medicaid no longer administer this part of the benefit as of January 1, 2006.  State Medicaid budgets will continue to pay 90 percent of the cost of dual-eligible pharmaceuticals through the phased-down state contribution, sometimes termed the "clawback."   
     State Medicaid programs can claim federal matching funds for coverage of Part D excluded drugs for dual eligibles. HHS has determined that if a state provides coverage of any excluded drugs to its non-dual eligible Medicaid population, it must provide that same coverage to its dual eligibles. In addition, states may use state-only funds to offer wrap around coverage to dual eligibles for additional (for example, non-excluded) drugs not included by Medicare drug plan formularies. States may provide this supplemental coverage through their Medicaid program or through a State Pharmaceutical Assistance Program (SPAP).  
     10 states report Medicaid agency ongoing involvement in co-payment assistance for dual-eligibles, as noted in Table 2 below.  Other Medicaid agency benefit changes are beyond the scope of this report, but will be described in future publications. 
     An HHS survey of 47 state Medicaid programs in December 2005 showed that 45 Medicaid programs will continue to cover non-prescription drugs, 46 states will cover benzodiazepines, 45 states will cover barbiturates, 35 will cover prescription vitamins and mineral products and 32 states will cover drugs for symptomatic relief of cough and colds.    [Source: DUAL ELIGIBLES’ TRANSITION: PART D FORMULARIES’ INCLUSION OF COMMONLY USED DRUGS, Office of the Inspector General, HHS, January 2006].

Summary of Major State Features: Table 2, directly below, summarizes the major features of state pharmaceutical assistance programs designed to wrap around Part D.  The Table describes programs in more than 20 states.  Data is based primarily on state laws enacted in 2005-06, plus more recently established state policies, and may not reflect exceptions for certain populations, sliding scale benefit variables and late-breaking regulatory requirements promulgated after January 2006.  Any enacted law changes will be added to future editions of this report.   Two states, Kansas and Nebraska, do not have SPAPs, but are reported to provide wrap around assistance only to dual-eligibles through the Medicaid agency and are included in the tables below.

    
TABLE 2
STATES PROVIDING OR AUTHORIZING ADDITIONAL, SUBSIDIZED “WRAP AROUND” BENEFITS TO MEDICARE ENROLLEES IN 2006

STATE	Quali-fied status	Wrap around authorized by	Maximum income, individual (% of '06 Federal Poverty)	Premium help	Deduc-tible help	Copay-ment help	Coverage gap (>$2,250) help	Moderate income help 250+% FPL	Persons with Disa-bilities under age 65	Auto-matic-enroll-ment autho-rized
Alaska	SPAP, M	’05 law, new	175%	Yes	Yes	No	3	No	No
Arizona	Non	'06 law, new	200%	No	No	Yes	No	No	Yes
Connecticut	SPAP, M	’05 law	218.3%	Yes	Yes 1	Yes 1	Yes 100%	No	Yes	Yes
Delaware	SPAP, M	’05 law	200%	Yes	Yes	No	Yes	No	Yes
Hawaii	Non Medicaid	’05 law, new; Not operational  '06 Medicaid regs.	100% 150%	Yes 2,3	Yes 2,3	Yes 3 Yes 7	Yes 2,3	No	Yes Yes 7	Facilitated
Illinois	SPAP+	’05 law	216.5%	Yes	Yes	Yes 1	Yes	No	Yes
Indiana	SPAP, M	'05 law, '06 regs.	150%	Yes 5	No 5	No 5	No	No	No	Yes
Kansas	Medicaid	'06 Medicaid regs.	135%			Yes 7			Yes 7
Kentucky	Non	’05 law, new      Not operational	150%	Yes 3	Yes 3	Yes 3	Yes 3	No	Yes 3
Maine	SPAP, M	’05 law	185%	Yes	Yes	Yes 1	Yes	No	Yes
Maryland	SPAP	’05 law	300%	Yes >$10	Yes 100% 3	Yes 3	Yes 3	Yes 300%	Yes	Yes
Massachusetts	SPAP, M	’05 law	500%	Yes	Yes	Yes	Yes	Yes 500%	Yes 188%	Yes 5
Missouri	SPAP, M	'05 law	200%	Yes	Yes	Yes			Yes	Yes
Montana	SPAP	’05 law, new	200%	Yes	Yes	No	No	No	Yes
Nebraska	Medicaid	'06 Medicaid regs.	135%			Yes 7			Yes 7
Nevada	SPAP	’05 law	236.4%	Yes	No	No	Yes	No	Yes
New Hampshire	Non	’05 law, new; Not operational	150%	Yes 2,3	Yes 2,3	Yes 2,3	Yes 2,3	No	Yes	Yes
New Jersey	SPAP	'05 law	316.2%	Yes	Yes	Yes	Yes	Yes 316%	Yes	Option
New York	SPAP	’05 law	357.1%	No	Yes	Yes 1	Yes	Yes 357%	No	Facilitated
North Carolina	SPAP	'06 change	175%	Yes	No	No	No	No	No
Pennsylvania	SPAP	'06 law	240%	Yes	Yes	Yes 1	Yes	No	No	Yes
Rhode Island	SPAP	pending	392%	4	Yes	4	Yes	Yes 392%	No
South Carolina	SPAP	'05 law	200%	No	No		Yes	No	No	Facilitated
Vermont	SPAP+	’05 law	225%	Yes 1	Yes	Yes	3	No	Yes	Yes
Virginia	SPAP	'06 program
Washington	Non	'06 law		No	No	Yes	No	No		No
Wisconsin	SPAP+	’05 waiver	240%	No	No		6	No	No	No

OTHER STATE PROGRAMS WITH SOME WRAP AROUND FEATURES

This summary table does not include all Medicaid program benefits. See note 7 below
1 – State can or will pay the portion that is higher than the standard state copayment or premium.
2 – Applies primarily to non-dual-eligible enrollees up to 150% of FPL, or duals between 135% and 150%.
3 – May be authorized in statute, but not currently established as a benefit.
4 - Under review or not yet determined.
5- Indiana changed benefits as of 7/1/06, to provide premium payments but no longer provide copayments and deductibles. 
6 - Because of its 1115 Pharmacy Plus waiver, valid through 2007, WI does not describe its benefit as a wrap around.  Enrollees over 200% FPL may be able to obtain benefits for expenses above $2,250.
7 - Benefits are limited to Medicaid-Medicare dual-eligible enrollees only; administered by Medicaid agency, not an SPAP. See Table 3 below.
8 - FCHA and WSHIP are offered only to uninsurable residents.  Enrollees must pay a substantial monthly premium for health insurance in order to obtain this wrap around coverage.

The states and programs listed in the following tables will offer state-funded pharmaceutical services as of January 1, 2006, or are engaged in negotiations to offer such services.  Most of the information provided is based on signed laws enacted in 2005, but not yet implemented as of the completion of research on this report.  Some features authorized by state law may not be available or implemented for early 2006. 

Updated: 11/27/05; 12/29/05; 7/28/06
Sources: Governor's office 12/05; SeniorCare website 12/20/05 & 7/28/06; interview with Sherry Hill 7/28/06.

ARIZONA	Medicare Copayment plan
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
Benefits	AHCCCS will pay for 100% of the $1 to $5 pharmaceutical copayments for residents enrolled in both Medicaid and Medicare.
Special features	No special enrollment is required for dual-eligibles once enrolled in Mediaid and Medicare.   Arizona also continues to offer the CoppeRx Card® Prescription Discount Program- see below
Est. # of beneficiaries	An estimated 87,000 dual-eligibles will be eligible.  (9/06)
2006 and future issues	Arizona also continues to offer the CoppeRx Card® Prescription Discount Program, a plan created by Governor Napolitano "to provide significant discounts on prescription drugs for all Arizona residents." Claimed savings "typically range from 15% to 55% from the overall retail price." The program is run by RxAmerica, a subsidiary of Longs Drug Stores, but purchases may be made at more than 500 community-based and chain pharmacies.   There is no enrollment fee to participate. There were 1,100,000 residents with cards
Contact information	Arizona Health Care Cost Containment System (AHCCCS)   Toll-free: 800-770-8014; policy: 602-417-4269 http://azahcccs.gov/site/ http://www.azahcccs.gov/PublicNotices/PressReleases/PR_MedicarePartD.pdf (9/21/06)

Updated: 6/30/05 & 11/27/05
Sources:  http://www.connpace.com/pubs/SFY05Annual.pdf

Updated 12/12/05, 1/4/06 & 7/13/06.

Updated: 12/15/05; 3/28/06
Sources: HI SB 18 (CD 1); Interview with Dept of Human Services 12/05

Updated: 12/15/05, 3/1/06 & 7/13/06.
Sources: SB 973 and Bill Analysis (5/24/05); Governor's new release (7/1/05); Scott McKibbin presentation to NCSL, 12/8/05; Governor's office (7/11/06).

INDIANA	HoosierRx
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/

Updated: 12/29/05, 1/31/2006 & 7/17/06
Source: Hoosier Rx website (12/29/05); Interview with Governor's office 12/29/05 and ; HB 1325; HB 1251; IAC Title 405, Art. 6; e-mail and telephone correspondence with Brian Smith, PhRMA.

KANSAS	Medicare-Medicaid dual-eligible Copayment plan
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.
Benefits	Medicaid will pay the $1 to $5 Rx copayments.
Special features	The terms of this limited benfit were first reported by NASMD in November 2006.*  Other details are not available at the time of this update or have not been confirmed by NCSL.
Est. # of beneficiaries
2006 and future issues
Contact information	Kansas Medical Assistance, http://www.srskansas.org/ISD/ees/eanddmedical.htm

Updated: 11/15/06
Source: * National Association of State Medicaid Directors (NASMD) report, "State Perspectives on Emerging Medicaid Pharmacy Policies and Practices" 11/06. 

KENTUCKY	Kentucky Pharmaceutical Assistance Program
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

Updated: 1/1/06

Updated: 6/1/07
Sources: Chapter 401 of 2005; Interview with Jude Walsh, Maine Special Asst for RX, 6/07
 

Updated: 12/15/05, 7/18/06 & 10/3/06.
Sources:  Text of MD 2005 law; Interview with MD Program Plan Analyst 12/05; interview with Chris Coats, Maryland Medicaid 7/18/06.

MASSACHUSETTS	Prescription Advantage
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.
Emergency gap coverage - 2006	Wrap-around special law passed Dec. 2005 provides for one-time thirty-day supply of any medication between 1/06 and 6/06.
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

Updated: 12/19/05 & 7/28/06
Source:  presentation by Beth Waldman, MA Medicaid 6/7/05; CMS statement 8/29/05; websites of EOEA 12/05; e-mail correspondence with Randy Garten, Dir. of Prescription Advantage (Exec. Office of Elder Affairs) 7/28/06.

MISSOURI	"MoRx"; Missouri Rx Plan  (replaced Missouri Senior Rx)
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."
Emergency gap coverage - Jan. 2006	State covers prescriptions when Medicare payment cannot be adjudicated.  Began 1/17/06. Department of Social Services announcement.
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.

Updated: 1/5/06, 3/16/06, 7/17/06, 11/2/06
Sources: MO legislative and agency web sites, 12/05; telephone conversation with Jerry Simons, Executive Director of Missouri Rx Plan.

MONTANA	Big Sky Rx Program
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.
Emergency gap coverage - Jan. 2006	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.
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/

Updated: 12/15/05 & 7/18/06
Sources:  Website; interview with Bureau Chief of Acute Services and Medicaid Pharmacy Programs 12/15/05; interview with Gayle Shirley, MT Public Information Office 7/18/06.

NEBRASKA	Medicare-Medicaid dual-eligible Copayment plan
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.
Benefits	Medicaid will pay the $1 to $5 Rx copayments.
Special features	The terms of this limited benfit were first reported by NASMD's November 2006 report.*  Other details are not available at the time of this update or have not been confirmed by NCSL.
Est. # of beneficiaries
2006 and future issues
Contact information	Nebraska Medicaid, http://www.hhs.state.ne.us/med/medindex.htm

Updated: 11/15/06
Source: * National Association of State Medicaid Directors (NASMD) report, "State Perspectives on Emerging Medicaid Pharmacy Policies and Practices" 11/06.