ACEUTICAE BENEFITS UNDER STATE EDlCAL ASSISTANCE PROGRAMS DECEMBER 6982 Compiled by NATIONALPHARMACEUTICAL COUNCIL, INC Iw.0 1%~ST~EET.N. W. WISHINGTON.D.C. 20005 (202) 659.2121 TABLE OF CONTENTS Introduction Pages NPC Stateme~t.................... 1- 2 Selected Background Information, - pharmaceutical Benefits Under Medical Assistance Programs ............. 3-18 Proposed Administration Medicaid Cutbacks and "New Federalism" ............ 19-21 Overview Statement and H.H.S. Regional Administrators and Associate Regional Administrators .................... 22-25 State Medicaid Drug Program Administrators, Title XIX, Medical Assistance Programs ........ 26-32 Charts I. Vendor Payments for Prescribed Drugs (By State) 1976-1981 11. Vendor Payments for Prescribed Drugs by Category of Aid (By State) FY-1981 111. Federal Medical Assistance Percentage Federal/State Matching Funds IV. Medicaid Services State-by-State, December 1, 1980 (Latest Table) Medical Assistance Drug Programs (Alphabetically by state and/or territory) -Data submitted directly to NPC unless otherwise noted: 1, Benefits Provided and Groups Eligible 2. Drug Program Recipients 3. Expenditures for Drugs by Fiscal Year 4. Orug Program Administration 5. Provisions Relating to Prescribed Drugs General Exclusions Formulary Prescribing or Dispensing Limitations Prescription Charge Formula TABLE OF CONTENTS (continued) 6. Miscellaneous Remarks 7. State Medicaid Officials, Consultants, and Committees 8. Executive Directors of State Pharmaceutical, Medical, and Osteopathic Medical Associations The National Pharmaceutical Council is an association of prescription drug manufacturers maintaining substantial programs of research and development that place special emphasis on product quality. NPC is dedicated to the enhancement of the quality and integrity of pharmaceutical services involving the manufacture, distribution and dispensing of prescription medications and other pharmaceutical products. The council sponsors continuing programs and special projects to demonstrate the contributions its members and their products make to high- quality, cost-effective health care. Those programs are directed principally to organized pharmacy, medicine, consumer leaders, and government officials who administer public health care programs, with special emphasis directed to leaders and officials at the state and local levels. The Council concentrates on establishing cooperative programs, research efforts, and information exchanges to advance the interests of its members. NPC recognizes tho importance of Medicaid in the nation's health care and the significance of the levels of care made available to patients receiving benefits under such a program. The Council shares the prevailing view of public health and public assistance officials that these patients should receive the same quality of medical care as do other patients in the community. It is our view that this quality concept should apply equally to pharmaceutical products prescribed and administered under medical assistance programs. We believe the Council can be of assistance by providing information and reference material in consolidated form on the existing programs. We also want to be of service to medical assistance program and public health officials in the development, implementation and operation of the soundest possible pharmaceutical programs in each state. To this end, we continue to make state by state reviews of the Medicaid programs which are reflected in the current compilation. The revisions of "Pharmaceutical Benefits Under State Medical Assistance Programs" include many changes made since the implementation of Title XIX of PL 89-97 (enacted as the Social Security Act Amendments of 1965) and subsequent amendments to the Social Security Act relating to Medicaid as well as changes made by an individual state program. If any errors or omissions are noted we would appreciate being notified as we want the compilation to be as helpful as possible. We acknowledge with appreciation the cooperation and assistance of the many state program officials and their staffs, state pharmaceutical associations, medical societies, and others in supplying data on their state programs. The Council also recognizes the importance of liaison and cooperation among Medicaid program officials and executives of many professional associations, and offers its services in the futherance of these relationships and our mutual objectives. PHARMACEUTICAL BENEFITS UNDER STATE MEDICAL ASSISTANCE PROGRAMS (Provided under Title XIX of the Social Security Amendments) This compilation of data on State Medical Assistance Programs (Title XIX) has been prepared to present a general overview of the characteristics of state programs together with more detailed information on the pharmaceutical benefits provided. This latter body of data is referred to in the compilation as the Medical Assistance Drug Program. The following information is provided for each state: 1. Recipient groups eligible for benefits. 2. Brief description of the Medicaid Program, 3. Scope of the State Drug Program. 4. Existing restrictions or limitations on drugs. 5. Data, when available, on case loads or persons eligible to receive health care benefits including recipients of pharmaceutical benefits. 6. Medicaid or public health officials. 7. Pharmacy and medical consultants to the state programs. 8. Pharmacy and medical advisory committees. 9. State medical and pharmaceutical association executives. Fifty-three of the fifty-four jurisdictions have Title XIX programs in operation, with approved state plans. Three of the 54 jurisdictions with Title XIX programs do not currently provide pharmaceutical benefits through the vendor payment systen. (See Chart IV, Medicaid Services State by State) The groups eligible to receive benefits provided under a Title XIX Medical Assistance ("Medicaid") Program vary from state to state as follows: 1. States covering only the No. of States categorically needy (CN) designated in the compilation as Money Payment Recipients . 20 2. States covering (1) above plus the category-related medically needy . ~ 3 4 Welfare Medical Care or Public Assistance Medical Care programs generally available under earlier Social Security Titles include the following programs: -Title Program Title Enacted I - OAA - Old Age Assistance and MAA - Medical Assistance for the Aged (Kerr-Mills*) ....... 1935 IV - AFDC - Aid to Families with Dependent Children ....... 1935 X-AB - Aid to the Blind ........ 1935 XIV - APTD - Aid to the Permanently and Totally Disabled ........ 1950 XVI - A consolidated program for OAA, AB, APTD or for such aid and MAA ............. 1962 General Assistance (State Funds Only) (SFO) Medical Care and Services Provided: The Federal law provides a comprehensive list of services that may be included in a state plan. The reader should refer to each individual state for the program benefits provided. (See Chart IV) The full list of medical care services that may be provided under the current program is as follows: **1. Inpatient Hospital Services (excludes: tuberculosis and mental institutions) **2. (A) Outpatient hospital services (B) Rural health clinic services, including ambulatory services offered by a rural health clinic and otherwise included in the state's Medicaid plan. **3. Other Laboratory and X-Ray Services **4. (A) Skilled Nursing Facility- Services (for individuals 21 or over) (B) Early and Periodic Screening, Diagnosis, and Treatment for physical and mental defects for eliaibles under 21 2 (C) Family Planning Services **5. Physicians' Services 6. Medical and Remedial Care recognized under state law and provided by licensed practitioners 7. Home Health Care Services 8. Private Duty Nursing Services * Enacted in 1960. **Basic Service (1-5), minimum or "basic five" 5 1982 Clinic Services Dental Services Physical Therapy and related services Prescribed Drugs, dentures and prosthetic devices, and eyeglasses prescribed by a physician skilled in diseases of the eye or an optometrist - whichever the individual may select Other Diagnostic Screening, Preventive and Rehabilitative Services Inpatient Hospital, Skilled Nursing and Intermediate Care Facility Services for individuals 65 years of age or over in an institution for tuberculosis or mental diseases Intermediate Care Facility Services Inpatient -psychiatric - hospital services for individuals under 21 Other Medical or Remedial Care recognized under state law and specified by Secretary, Department of Health and Human Services (HHS). Services That Must Be Pyovided: For the Categorically Needy: States participating in a Title XIX program must provide the basic services 1 through 5, as listed above. For the Medically Needy (if included in state plan): The states have choices. They must provide the "basic five" or any 7 of the first 16 services listed in Title XIX, Section 1905(a) of PL 89-97, as amended. a plan which covers the medically needy that includes inpatient hospital or skilled nursing facility services for the medically needy, must provide physicians' services for the eligible medically needy when they are patients in a hospital or skilled nursing facility even though physicians' services are not otherwise included for the medically needy. Certain home health services and supplies must be covered for all categorically needy individuals 21 years of age or older. Also, all categorically needy individuals under 21, if the plan offers these individuals skilled nursinq facility (SNF) services as well as