Medicaid: A Brief Overview and Case Studies on Access to Prescription Drugs
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Transcript of Medicaid: A Brief Overview and Case Studies on Access to Prescription Drugs
Medicaid: A Brief Overview and Case Studies on Access to Prescription Drugs
Miriam HarmatzFlorida Legal ServicesFebruary 25, 2009
Medicaid Eligibility
• Need categorical connection
- Aged or disabled
- Child or parent
• Low income
- Parent with child: income must be below
$682 and assets less than $2,000
- Aged, blind or disabled: income must be below $657
assets less than $2,000
Medicaid Structure
• Federal/State funding
• State flexibility but federal law controls
42 U.S.C. § 1396 et seq.
• Entitlement*
• Complicated
Prescription Drug Benefit
• $$$: huge budget item, with costs rising more quickly than other benefits
• Prior authorization: tool for controlling costs required for certain brand name drugs and drugs not on PDL
• Result: patients did not get their meds
Due Process for Prescription Denials
Hernandez et al. v. Medows, 209 F.R.D. 665 (S.D. Fla 2002.)
Medicaid statute 42 U.S.C. § 1396a(a)(3)
Goldberg v. Kelly
Medicaid regulations 42 C.F.R. § 431.200 et seq.
14th Amendment
Importance of data, experts and settlement
Discovery regarding drug denials
Relationship to class and permanent injunction
Complexity of benefit: settlement best outcome
What drugs can be prescribed?
On label
Off label
Medically accepted indication
42 U.S.C. § 1396r-8(k)(6)The term “medically accepted indication” means any use for a covered outpatient drug which is approved under the Federal Food, Drug, and Cosmetic Act [21 U.S.C.A. § 301 et. Seq.], or the use of which is supported by one or more citations included or approved for inclusion in any of the compendia described in subsection (g)(1)(b)(i) of this section.
• Compendia• Applies to Medicaid & Medicare Part D
Edmonds et al. v. Levine
Off label marketing abuses
State response
Adverse impact on recipients
Structure of prescription benefit
Rebates
Very limited grounds for denial
Role of Compendia
Can PA
Medicaid Reform
Goal to block grant/privatize Defined benefit/predictable spending Plans determine amount, duration, and
scope PD limits on # Lack of data regarding denials
Medicare Part D
Privatized model
Limited government role
Lack of denial data or info on price negotiations
Lack of uniform PDL structure
“Medically Needy” hurt by Part D
Categorical connection: Aged or disabled– over income or over assets; share of cost (SOC) like
deductible Before Part D those with high drug costs met SOC
– Full Medicaid-including drug benefit/no co-payments– Full Medicare cost share benefit deductible, co-insurance,
co payments After Part D
– Lost Medicaid– Huge Part D co-payments– No Medicare cost sharing benefit
Medicare Part D “Victim”
RB needs transplant Income $1200/month, plus Medicare Medically needy share of cost (SOC) $ 900 Transplant drugs Part B: $ 700 All other drugs covered by Part D Cannot meet Share of cost; or afford cost of
Part B drugs Rejected for evaluation
Is health care right or responsibility?
If right- for everyone or just the “categorically connected” poor?
If right for everyone, cover every medically necessary service?
Government v. private sector?