Maryland ADAP

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Maryland ADAPMedicare Part D

• Presented by
• Linda J. Anders, MPH
• Center for Client Services
• August 2006

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Background Info

• Funding
• ADAP Model
• Clients

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1. Funding 2006-2007

• Title II Base Services- 7,813,010
• (- 299,694 decrease)
• Title II ADAP Earmark - 27,938,941
• (355k increase from previous year)
• Title I Wash., D.C., Suburban Maryland EMA
  238,351
• Emergency Drug Assistance (New funding)

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2. ADAP Model

• The Maryland ADAP (MADAP) is uses the pharmacy
  reimbursement model. MADAP uses the Maryland
  Medicaid pharmacy network, and the Maryland
  Medicaid pharmacy benefits manager. This means
  that any pharmacy with a Maryland Medicaid
  provider number is able to electronically bill
  MADAP.
• MADAP uses the 340b and ADAP Supplemental rebate
  model (for GY 05, MADAP received approximately
  11.1 m in rebates)

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3. Client Program Information

• Eligibility for MADAP
• Applicants must be Maryland residents,
• Have annual income not more than 500 of FPL
  (equal to 49,000 for a household of one in 2006,
  with no asset limit), and
• Submit a medical form signed by prescribing
  clinician stating the client is HIV positive, has
  a need for a MADAP-covered drug, and current CD4
  viral load lab results.
• Federal Poverty Level

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MADAP Enrollment Cost per ClientJuly 2005
through June 2006(FY 2006)

• Average MADAP enrollment 3,279 clients per month
  over the past 12 months, a 13 increase over FY
  2005 monthly average of 2,908 clients.
• Average gross drug (before rebates) cost per
  client 1,168 per month, 5 less than the
  average cost per month during FY 2005 (1,229 per
  client per month).

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MADAP Client Geographic Distribution
1.7 m on 246 clients
12.8 m for 1,485 clients
19.5 m for 2,899 clients
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Maryland HIV Stats
Male 62 Female 38 White 13 Africa
n-American 84 Other
1 Hispanic 3 0-12
yrs lt1 13-19 yrs lt1 20-29 yrs 10 30-39
yrs 27 40-49 yrs 40 50-59 yrs 17 60 yrs
5 HetSexPR PI 56 IDU 22 MSM 17
approximations
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Maryland Health Care
Medicaid (MA) Medically needy, permanent legal
US resident, maximum income is 350/month, assets
not more than 2,500 for a household of one
broad formulary with preferred drug
list. Maryland Primary Care Program (MPAP)
Income maximum for household of of one is 116
FPL, assets not more than 4,000 broad
formulary, prescriptions and primary health care
accessed through a managed care organization HIV
meds fee for service (effective July 1, 2006
previously the Maryland Pharmacy Assistance
Program) Senior Prescription Drug Assistance
Program (SPDAP) Provides up to 25 a month
toward Medicare Part D premiums open to all
Medicare beneficiaries with a maximum income of
300 FPL and assets not more than 10,000
(effective January 1, 2006).
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Medicare Part D is Coming! The Plan.

• Implementation Phases Customer service was to
  be our main focus, whether the customer was a
  client, a Maryland resident, a pharmacist, or a
  medical provider.  
• Prior to the open enrollment period, the focus
  was on determining MADAPs policies, and
  educating the HIV community on the Part D
  benefit, the impact on Medicaid, MPAP, and MADAP
  clients, and all assistance programs.
• Once the enrollment period began through the end
  of the enrollment period, the focus was on
  getting people into the plan to best meet their
  needs.
• From January 1st on, pharmacists and prescribers
  were given full attention and assistance getting
  medications paid for and to the clients.

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Phase 1Medicare Part D Education

• I attended all meetings, trainings, and
  conferences that mentioned the Medicare Part D.
• Conference Calls
• SHIP presentations
• State Medicaid presentations
• Thank NASTAD, and all my colleagues that helped
  shed light on this subject!

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Medicare Part D Learning Curve
It was immediately apparent during those sessions
that the information presented offered little
detail specifically for the HIV/AIDS community,
and little guidance for HIV medical case managers
and clinicians. We determined that MADAP would
coordinate benefits with the PDPs, paying
co-payments, co-insurance, and premiums for MADAP
clients as needed. And so, I created a
Maryland-specific training for the HIV/AIDS
community so that questions regarding all state
pharmacy programs could be addressed. And,
began the traveling road show, with the goal of
training any group who was willing to listen
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Estimating Impact
Using data in the client eligibility system, we
were able to identify 600 MADAP clients who had,
or were likely to have, Medicare. Based on
information provided by clients, information
enrollment in Medigap plans, age, and disability
status. We saw estimated that an additional 900
HIV positive, low-income MPAP clients with
Medicare who were going to be unenrolled from
MPAP and auto-enrolled in a Part D Plan, without
auto-enrollment into the Low Income Subsidy.
This group of people were also eligible for MADAP
now because they were no longer eligible for
MPAP. The quest for 900 Marylanders began.
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The Road Show The Search for 900 Marylanders
Between September 1st and December 31st, I
personally trained over 300 case managers,
medical providers, pharmacists and consumers on
the impact specifically on the HIV community. I
targeted the 900 low income MPAP clients as the
most vulnerable population because they were
being unenrolled from a MPAP and auto-enrolled
into Medicare Part D. Case managers were given
regional estimates for how many they should be
contacting to assist with the transition.
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Phase 2Team D
Team D noun. A five-person group, trained to
provide comprehensive information to the HIV
community on Medicare Part D, including selecting
a plan, application to SSA Low Income Subsidy,
plan formularies and exception processes, and
trouble shooting. Made up of a PA-C, insurance
eligibility specialists, the MADAP Administrator
and me! Team D was available to all case
managers, clients and providers seeking
information and application assistance. Special
attention went to case managers so that they
would be able to independently assist their
clients
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Enrollment Begins
Between December 1st and May 15th, Team D
directly assisted over 200 clients with
enrollment into a Part D, and the Low Income
Subsidy and SPDAP, as applicable. During the
first two months, the average phone call took an
average of two hours, with the end result of the
caller being enrolled in a plan and the SSA
application submitted. This average call length
dropped to one hour after Team D became familiar
with the different PDPs benefit packages.
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Average Monthly Enrollment in MADAPActual
January 2003 through June 2006 Projected July
2006 to June 2007
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MADAP 1993-2006
Dollars Pharmacy Claims before Rebates (Monthly)
Enrollment (Monthly)
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Phase 3Beneficiaries go to the Pharmacy
January was quieter than expected, partially due
to the significant number of early refills made
in December. February March were anything but
quiet. Pharmacists were at a loss for processing
claims, and defaulted to throwing their hands up
in the air. Fortunately, our clients the case
managers knew to refer them to MADAP for help. We
assisted hundred of pharmacists with identifying
the correct PDP, working with clients to resolve
Low Income Subsidy issues, conference calling
with the Medicaid office, and doing claims
overrides when necessary. The pharmacy trouble
shooting calls were initially, and primarily,
handled by the MADAP pharmacy claims manager, and
when problems were related to PDP or LIS
enrollment, the calls were forwarded to me.
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Medicare Part D, One Year Later
MADAP staff continue to assist clients with
enrollment into Medicare Part D as clients become
newly enrolled in Medicare. Open enrollment in
Medicare Part D is November 15th through December
31st 2006. People will be able to sign up for
the program and change Prescription Drug Plans
during that time. Though the volume of calls
has dropped significantly since May, MADAP
continues to problem solve access to medications
issues with clients, case managers, pharmacists,
and providers.