Jeb Bush's Devious Prescription Drug Plan
Florida's prescription drug program for seniors "The
Silver Saver Plan" is more of a fraud than we ever imagined! With little
attention Governor Bush through the Agency on Health Care has agreed to block
grant Medicaid spending for Senior citizens - this was a little known condition
of the Silver Saver waiver.
"The waivers have an aggregate spending cap for ALL services provided to
ALL senior Medicaid beneficiaries."
While attending the Families USA Conference in Washington, DC two weeks ago
we received some very troubling information pertaining to the "Silver Saver"
Prescription Drug program. First a little background. You'll recall that toward
the end of the Session last year the Governor started touting his new prescription
drug plan - the Silver Saver Plan. This was promoted as a way to take the existing
state pharmacy assistance program which provided up to $80 a month to Seniors
between 90% and 120% of poverty. This program was totally funded with state
dollars. The Silver program expansion was based on a new federal waiver that
allowed the state to draw down federal matching Medicaid dollars. So, the Silver
Saver program covered seniors from 88% (to pick up the Seniors cut off of the
Meds/AD (Medicaid for the aged and disabled program) to 120% at $160 (double
the previous $80). Because there was now federal match money involved more seniors
were eligible for the program.
HOWEVER, what was not stated and what we did not know until recently is that
in accepting the federal waiver the state agreed to a GLOBAL CAP ON ALL MEDICAID
SPENDING ON PEOPLE OVER 65. This cap is not limited to prescription drugs but
applies to ALL spending on Seniors including nursing homes, long term care,
community based services.
THIS COMPONENT WAS NOT DISCUSSED BY THE LEGISLATURE, IT DOES NOT APPEAR IN THE
WAIVER REQUEST AND WOULD NOT BE KNOWN UNLESS YOU READ THE PARTICULARS OF THE
WAIVER.
There are 4 states that have been approved for the "Pharmacy Plus"
waiver. Each state negotiated different caps on their programs. According to
our national sources Florida's cap is about 8% annually. That means that once
Florida spends 8% more than last year on ALL programs for Senior citizens we
will hit the cap and their will be no return of our tax dollars being held by
the federal government. This will be done over a 5-year period.
Here is some background on the Pharmacy Plus Waivers provided by Families USA.
(full info. at Familiesusa.org)
"Pharmacy Plus" waivers are single-benefit Section 115 waivers for
prescription drug coverage. Pharmacy Plus waivers must meet certain requirements,
as follows:
The must be limited to providing drug coverage to individuals not eligible for
full Medicaid benefits. Income can be as high as 200 percent of the federal
poverty level. (Florida goes to 120%)
The waiver must have some sort of primary care component. Incorporating referrals
to Community Health Centers or having some sort of care coordination through
a contracted Pharmacy Benefits Manager (PBM) can meet this requirement.
They must be budget-neutral over the period of the waiver (five years).
The state must spend some of its own funds to provide the pharmacy benefit to
the new population: If the state is moving an existing pharmacy assistance program
into Medicaid, it must expand that existing program in some way rather than
simply shift its current costs into Medicaid.
Common Waiver Structure
The approved and pending waivers share certain features that are outline below.
The content of the waivers (approved and pending) appears in the chart, "Selected
Features of State Pharmacy Plus 115 Waivers." Common features of these
waivers include the following:
All provide comprehensive prescription drug coverage to seniors, generally covering
the same drugs as the Medicaid program. The level of coverage, however, varies
substantially. Some states have dollar caps on coverage. For example, Florida
will only cover $160/month. Other states have deductibles or enrollment fees.
(Florida is the only approved waiver that limits monthly coverage). Most cap
the number of individuals who can enroll in the expansion program. (If the Pharmacy
Plus program is subsuming an existing Pharmacy Assistance Program, the enrollment
cap would include the patients transferring from the
existing program into Pharmacy Plus.)
All base five-year budget neutrality calculations on the assumption that improved
access to prescription drugs will mean seniors will be healthier and, as a result,
fewer will spend down to Medicaid eligibility ("diversion from spend-down).
In developing budgets, most states have relied on findings from a New Hampshire
study that was reported in the New England Journal of Medicine in 1991. That
study showed
that restricting Medicaid beneficiaries' access to drugs correlated to an increase
in nursing home admissions and other health care spending.
THE WAIVERS HAVE AN AGGREGATE SPENDING CAP FOR ALL SERVICES PROVIDED TO ALL
SENIOR MEDICAID BENEFICIARIES. THIS CONTRASTS TO THE APPROACH USUALLY TAKEN
IN WAIVER APPLICATIONS, IN WHICH THE SPENDING CAP IS LIMITED TO THE EXPANSION
POPULATION OR IS SET AS A PER CAPITA CAP RATHER THAN AN AGGREGATE CAP APPLIED
TO AN ENTIRE GROUP. THIS APPROACH, IN EFFECT, BLOCK-GRANTS MEDICAID FOR ALL
SENIORS, NOT JUST THOSE IN PHARMACY PLUS.
The waivers approved thus far subsume the states' existing Pharmacy Assistance
Programs, with some coverage expansion over the current program. States need
to expand existing Pharmacy Assistance Programs beyond current benefits to show
budget neutrality: If the state is simply shifting an existing program into
Medicaid, it is difficult to argue that there will be expanded access to drugs
that will improve health and divert potential spend-down individuals from Medicaid.
Key Concerns with the Pharmacy Plus Waivers
While the waivers expand drug access for a new population, as they are currently
structured, they present several concerns. THE MOST CRITICAL CONCERN IS THE
WAIVERS SET MEDICAID SPENDING CAPS ON ALL SENIORS FOR ALL SERVICES. This is
particularly troubling given the administration's position that it will not
"bail-out" states that miscalculate budget neutrality.
This is a forerunner to President Bush's new proposal to block grant the entire
Medicaid program for non-mandatory coverage - which is about 52% of the program
- including prescription drugs.