nic Nationai Pharmaceutical Council Pharmaceutical Benefits Under State Medical Assistance Programs SEPTEMBER 19 9 3 \ \ /NATIONAL PHARMACEUTICAL COUNCIL, INC. Quality Through Research sRuceH COWIGEN HEA November 1993 MEMORANDUM. TO: Users of Pharmaceutical Benefits Under State Medical Assistance Programs FROM: Bruce Colligen, Editor Z SUBJECT: State by State Federal Medical Assistance Percentages In evaluating the 1993 Pharmaceutical Benefits Under State Medical Assistance Programs, it has ‘come to our attention that the Federal Medical Assistance Percentages (page 199) are incorrect. Please find enclosed the correct FMAP table. These percentages are used to determine the amount of federal matching for the states’ Medicaid programs, The table found on page 199 is the federal percentage assistance provided to AFDC programs. Please contact me at 703/620-6390 if I can be of any further assistance. Thank you. 1894 PRESTON WHITE DRIVE, RESTON, VIRGINIA 22091 (703) 620.6390 FAX (703) 476.0306Mark R. Knowles September 1993 Dear Reader: ‘Though healthcare reform is an evolving concept in Washington, DG, itis fast becoming a reality in many state capitols. States are engineering reforms specific to local circumstances, including moving Medicaid recipients into managed care settings. While we can not reasonably expect full ‘national reform until 1995 or later, Medicaid programs are undergoing considerable repositioning, now. ‘This twenty-eighth annual edition of the compilation, Pharmaceutical Benefits Under State Medical Assistance Programs, was prepared by the National Pharmaceutical Council to assist in your ‘evaluation of Medicaid program characteristics. NPC recognizes Medicaid as an important health ‘care component and believes that public assistance patients should receive the same quality of care as other patients in the community, hope you continue to find the information contained in the compilation valuable and to this end ‘welcome your suggestions for changes that better meet your needs. Sincerely, a kook — Mark R. Knowles President, Chief Executive OfficerPHARMACEUTICAL BENEFITS UNDER STATE MEDICAL ASSISTANCE PROGRAMS SEPTEMBER 1993 Compiled by ‘National Pharmaceutical Council, Inc. 1894 Preston White Drive ‘Reston, Virginia 22091 Editor: Research & Production: Bruce H. Colligen Mary Geil Swenson © 1993 by the National Pharmaceutical CouncilTABLE OF CONTENTS From the Editor . Pharmaceutical Benefits Under State Medical Assistance Programs . ‘Summary of Medicaid Demonstration Projects Under OBRA '89 and ‘90 Medicaid Vortary Consibuion and Provider Specie Tax Amendments of 1991 eee ae Glossary of Medicaid Terms . 6... cee eeseeee cette ccteeeerertenee ‘Acronyms State Medicaid Drug Program Administrators State Officials ..... sansnenien ys Regional Administrative Offices . HCFA Medicaid Bureau. . Federal Register 42 CFR Parts 413, 480, 447 and 45 CFR Pants 1 & 19 ‘and Limits on Payments for Drugs sees sceesevevseeeeereetestseeeeees ‘Specific Upper Limits for Multiple Source and “Other Drugs* . ‘abies (Program Characteristics and Statistics) 1. Medicaid Statistios: ‘A. Ranking of States Based on Medicaid Drug Expenditures .......... B. Title XIX Medical Assistance U.S. Totals by Type of Service . c. Medicaid Recipients and Vendor Payments . D. Vendor Payments for Prescribed Drugs (1987 — 1992) .. Recipients of Prescribed Drugs (1987 — 1992) F. Medicaid Drug Reimbursement Report . ... G. Average Expenditures per Recipient for Prescribed Drugs (1987 — 1992) . . H. _erceruage of Medal Expenditures Alocated to Pression Medication (1988 — 1992) ..... : Sone 1. Ranking of States by Dispensing Fee, 1983, Page 28. 31 39 40 85 - 56 .97 = 98 + 100 101 102 103 107 108Page J. Medicaid Limits on Prescription Drugs, by Jurisdiction eee eee. 108) K. Miscellaneous Medicaid Program Characteristics, 1993 i i "1 L. Drug Utilization Review Chart .........ceececeeee eee : 113 M. Patient Counseling Requirements eset as terstvosanner tl N. Introduction to HCFA 2082 Data Tables sees cece 116 ©. HCFA 2082 Data Tables Gases miubecaiee e601 4 5, 398 P. Federal Medical Assistance Percentage (FMAP) .......... 199 @. State Population and Demographics, 1992... ccs eeeeeeee eee ee caesar 200 FR. Number of Pharmacies, by Stato... . 06s seccteteeeeeeeeeeeeeeeee ds 204 S. Key Provisions of State Drug Product Selection Laws... 00.0... ccc vere ee es 202, 7, Expanded Drug Coverage for the Elderly .....5eeeeeceeeseeeee reese eee BOM U. State Medicaid Managed Care Programs... 206 V. "General Cash Assistance Programs ....... 5.5.0.5 Saeed au Medical Assistance Drug Progfams.. 208 (Alphabetically by State)Bruce H. Coligen, M.A Ester ‘September 1993, Dear Reader: It is my pleasure to present to you the twenty-eighth issue of Pharmaceutical Benefits Under State ‘Medical Assistance Programs. As discussions of health care reform dorinate the airwaves, Medicaid programs continue to grow and respond to the burgeoning health needs of the neediest Americans, It | with this same dedication that the National Pharmaceutical Council provides you with timely information and data on these programs. Founded in 1953 by companies engaged in the discovery, development, production, and marketing of innovative prescription medicines, NPC is dedicated to the enhancement of the quality and integrity of pharmaceutical services. Today, our twenty-nine member companies continue that commitment to pharmaceutical research and maintaining quality control standards. Toward this end, NPC undertakes educational activties and provides services to pharmacists, manufacturers, professional associations, colleges of pharmacy, physicians, medical schools, government offices, and consumers concerning key aspecis of health care. NPC services include providing information on the quality and cost-effectiveness of pharmaceutical products, the economics of drug programs, and the notable contributions of research oriented pharmaceutical manufacturers, ‘The information on each state Medicaid program was obiained from an NPC survey of state Medicaid rogram administrators and pharmacy consultants. Other statistics were reported by the HCFA Medicaid Statistics Branch, Department of Gommerce, and state pharmaceutical association executives, NPC acknowledges the cooperation and assistance of the many state Medicaid program officials and their staffs, state pharmaceutical associations, Health Care Financing Administration personnel, and thers in supplying data for this compilation. This publication would not be possible without the time and efforts of Mary Gail Swenson, Health Programs Coordinator at NPC, Sincerely, fee H. Colligen' Vice President, Health Prégrams National Pharmaceutical Council‘© Payment for services is made directly to health care providers by the state administering agency or ts representatives. ¢ Each state has a quality control system following uniform federal guidelines to uncover eligibility errors and to assure proper, efficient program administration. Errors are identified through a sampling process; eligibility reviews are conducted, and errors are comected. Medicaid accounted for $91.5 billion in federal and state expenditures for medical services in 1992. The program operates on the basis of a state ‘and federal division of responsibilities. The federal government establishes regulations, guidelines and policy interpretations which describe the broad outtine within which states ‘can tailor their individual programs, States ‘assume control and direction of operations, As ‘a result there are 56 (50 states, plus Guam, District of Columbia, Puerto Rico, Samoa, Norther Mariana stands and the Virgin Istands) distinctly ditferent programs in operation. Funding is shared between the two bodies, with the federal government matching state health care provider reimbursements of an authorized rate between 60% and 63% ‘depending on the states per capita income. (Gee index FMAP Tables) Federal law governs certain aspects of Medicaid, and requires that all persons who quaity for Aid to Families with Dependent Children (AFDC) and most persons who quality for Supplemental Securty Income (6SI) receive Medicaid coverage. The Federal Government requires states to provide a basic ‘et of services to people eligible for Medicaid and to reimburse providers of those services in certain ways. Reimbursement levels for many services are subject to federally established ceilings and, in some instances, floors. ‘State control over eligibility is substantial, because states establish eligibilty for AFDC which establishes eligibility for Medicaid. (The same does not hold true for SSI recipients, whose eligibiity is determined primarily by Federal criteria.) Furthermore, states may voluntarily extend Medicaid coverage to additional groups of people and expand the range of services covered. States also have ‘some latitude in defining reimbursement methods for physicians and other health care providers. Title XIX of the 1965 Social Security ‘Amendments provide the legislative basis for Medicaid. Medicaid should not be confused with Medicare, which was aiso established by the Social Security Amendments of 1965. Medicare is @ federally administered medical insurance program for the elderly, which is administered by the Social Security ‘Administration (SSA). ADMINISTRATION ‘Administration of the state Medicaid program is. vested In single state agencies, Within each agency, state plans must designate a medical assistance unit responsible for developing, analyzing, and evaluating the Medicaid program. The law further requires the states to ‘establish medical care advisory committees to advise the Mosicaid agency director about heaith and medical services. These comrnittees must include board certified physicians and other representatives of the health professions, members of consumer ‘groups, and the director of either the state public welfare or the public health department (whichever department does not run the Medicaid agency). Activities for administering the state Medicaid program include: program administration, Medicaid Management Information System (MMIS), claims processing activity, state administration, and waivers. Eligibility Determination and Program ‘Administration ‘States are allowed three options for administering coverage of SSI recipients (42 CFR 431.10(¢)): States electing to extend Medicaid to all SSI recipients can enter into an agreement with the Social Security Administration under Section 11634 of the Act for determinations of Medicaid eligibility; States electing to extend Medicaid eligibility to recipients of SSi can maintain eligibilty determinations on a state level; of ‘States electing the 209(b) option (where recipients of cash assistance under SSI are not automatically eligible for Medicaid) can requirecash assistance recipients to make a separate application for Medicaid. Thirty-one states elected to have federal determination. Five states elected to extend Medicaid to al recipients of SSI but maintain eiigibilty determination on a state level Fourteen states elected the 209(b) option. A state plan must be in operation statewide through a system of local offices under equitable standards for assistance and admin- istration that are mandatory throughout the state (42 CFR 431.50(b). However, the state may choose to administer the program at the state level or by political subdivision of the state. Forty-four states have chosen to ‘administer the Medicaid program on a state level, Sk states have chosen local (county) administration. A state plan must specity a single state agency, established or designated, to administer or supervise the administration of the plan (42 CFR 431.10(b)). Generally, the administering agency has been the state health agency, welfare agency, of an umbrella agency. A possible effect of the administering agency being the health department is that the welfare department has control over the intake of eligibles in the AFDC and SSI/SSP programs, individuals who automatically become eligible for Medicaid. ‘SERVICE COVERAGE The original Tite XIX legislation listed fiteen types of medical care elgibie for federal funding, The last one was very general in nature specifying that ‘any other medical care, and any other type of remedial care recognized Under state law* was eligible for federal suppor. Presently, 32 other medical services ‘are recognized as acceptable Medicaid services for which the state can receive federal assistance for funding if they elect to provide these optional services. MANDATORY SERVICES: Federal regulations penaining to Medicaid mandate that certain basic services be offered to all categorically needy persons. These services inciude: 1. Inpatient hospital services 2. Outpatient hospital services Physician services Other laboratory and X-ray services ‘Skilled nursing facility services (for persons twenty-one years of age or older) 8. Early and periodic screening, diagnostic, and treatment program (EPSDT) 7. Family planning services and supplies 8 Home health services 9, Rural Health Clinic Services 10. Nurse-midwife services 41. Pediatric and family nurse practitioners services 12, Certain federally qualified ambulatory and heatth center services pao REGULATIONS PERTAINING TO MEDICAID SERVICES: Federal regulations require that the amount ‘and/or duration of each type of medical and remedial care and sarvices furnished under a state's Medicaid plan must be specified in the state plan, and that these types of care and services must be Sufficient in amount, duration, ‘or scope to “reasonably achieve" their purpose. Each plan must include a description of the methods that will be used to assure that the medical and remedial care and services are of high qualty, and a description of the standards established by the state to assure high quaity care. ‘The regulations also require that fee structures be developed which will rssut in participation of a sufficient number of providers ‘of services in the program so that eligible persons can receive the medical care and services included in the plan at least to the ‘extent that these are available to the general population. The law further requires that services provided under the pian be available throughout the state. Recipients are to have freedom of choice with regard to where they receive their care, including an option to obtain their care through organizations that provide sorvices of arrange for their availabilty on a repayment basis, such as health maintenance organizaticns, MEDICAID ELIGIBILITY Medicaid is the primary source of health care coverage for the poor in America. Through it, medical services are provided primarily to those People who are eligible to receive cash pay- ments under one of the existing welfareprograms established by the Social Security ‘Act. Basically these eligible persons fall into ‘two categories - those whose eligibilty for Medicaid services is mandated at the federal level and those whose eligibility Is determined by the individual state, These categories are described in the sections below. Mandatory Coverage Every state, in order to receive Title XX funding, must provide Medicaid benefits to certain “categorically needy" persons. In order 10 be considered ‘categorically needy" for Medi- caid purposes, an individual must be recelving financial assistance (maintenance payments), ‘ be eligible for financial assistance, under Title XVI, Supplemental Security income for the Aged, Blind, and Disabled (SS), ‘The two largest of these ‘categorically needy" ‘groups are persons already receiving maintenance payments through the Aid to Families with Dependent Children program or ‘through the Supplemental Security Income program, Other groups that are categorically needy and thus automatically elgibie for Medicaid are recipients of mandatory state supplements and persons affected by increases in Social Security payments. MEDICAID SERVICE (Mandatory Services Indicated by Capital Letters) |. Professional Services PHYSICIAN SERVICES Chiropractors’ Services Podiatrists’ Services ‘Optometrists’ Services ‘Other Practitioners’ Services Dental Services (21 years and older) |. Nursing Care Services HOME HEALTH SERVICES (21 or older) Personal Care Services Private Duty Nursing NURSE-MIDWIFE SERVICES Adult Day Treatment Services PEDIATRIC & FAMILY NURSE PRACTITIONER SERVICES Il, Nursing Home Services SKILLED NURSING FACILITY SERVICES (21 years or older) vw vu. vil Intermediate Care Facility Services Skilled Nursing Facilty Services (under 21 years) Hospital and Clinic Services, INPATIENT HOSPITAL SERVICES. OUTPATIENT HOSPITAL SERVICES RURAL HEALTH CLINIC SERVICES FEDERALLY QUALIFIED HEALTH CENTER & OTHER AMBULATORY SERVICES Clinic Services Emergency Hospital Services Drugs, Supplies and Equipment Presoribed Drugs Dentures Eyeglasses (21 years or older) Hearing Aids (21 years or older) Prosthetic Devices ‘Special Services and Therapy INDEPENDENT LABORATORY & X-RAY SERVICES EARLY & PERIODIC SCREENING, DIAGNOSIS & TREATMENT (EPSDT) OF CHILDREN (under 21 years) FAMILY PLANNING SERVICES Diagnostic Services and Screening Services (21 years or older) Preventive Services Physical Therapy ‘Occupational Therapy Treatment for Speech, Hearing and Language Disorders Institutional Care Inpatient Psychiatric Services (under 22) Care in Tuberculosis institutions (age 65 or older) Care in Mental Institutions - Intermediate Care Facility Services (age 65 or older) Care in Mental Institutions - Skilled Nursing Fatility (age 65 or older) ‘Other ‘Transportation to and from medical services Enrollment in Medicare - Part B, Title XVll, ‘Supplemental Medical Insurance Enrollment in Medicare - Part A, Tite Xxvll Hospital Insurance BenefitsOptional Coverage In addition to the services listed as being mandatory of optional, Tile XIX specifies that “any other medical care, and any type of reme- dial care recognized under state law, spectiog by the Secretary of the Department of Health and Human Services," is acceptable as a Meci- caid service and eligible for federal support. In addition to the groups that must be covered by the state's Medicaid programs, there are ‘other groups that are “categorically needy" or ‘medically needy" who may be inciuded in Medicaid at the Option of each state. General Eligiblity Requirements In addition to designating that certain groups of people must be covered by a state’s Medicaid plan and defining other groups that may be ‘covered at the discretion of the state, the federal government specifies certain general requirements that must be met for Medicaid aligiblity. A state can provide coverage for Persons that do not meet these specified Fequirements, however, state andior local funds must be used to support the medical expenses of these individuals. A Medicaid agency that chooses to cover an optional group must provide Medicaid to all eligible individuals in that group. CHARACTERISTICS OF BENEFITS PROVIDED Inpatient Hospital Services Inpatient hospital services refer to services that are ordinarily furnished in a hospital for the care and treatment of an inpatient. The facility is one maintained primarily for the care and treatment of patients with disorders other than tuberculosis or mental diseases. There are seve- ral general federal limitations on inpatient hospital services which are applicable to all states with Medicald programs (42 CFR 440.10): ©The facility must be licensed or formally approved as a hospital by an offically Gesignated authority for state standard-setting; ‘¢ The facility must meet the requirements for participation in Medicaid; © The care and treatment of inpatients must 'be under the direction of a physician or dentist; and © The facilily must have in effect an approved utilization review pian, applicable to all Medicaid patients, unless a waiver has been granted by the Secretary of Health and Human Services. Jn addition to the federal imitations, each state may impose further limitations on inpatient hospital services. Outpatient Hospital Services Outpatient hospital services refer to preventive, ciagnostic, therapeutic, rehabilitative, or Paliative services provided to an outpatient. ‘There are three federal imitations that are imposed on these services: ‘© The services must be provided under the dicection of a physician or dentist; © The facility must be licensed or formally approved as a hospital by an officially designated authority for state standard-setting: and © The facility must meet the requirements for participation in Medicare, States are free to specify other limits on ‘outpatient hospital services and 42 states have chosen to do so. Rural Health Clinic Services Rural health clinic (RHC) services became a ‘mandatory service tor the categorically needy in July 1978, Each RHC is required to have @ nurse practitioner (NP) or physician's assistant (PA) on its stall, Therefore, a clinic can oniy be Certified if the state permits the delivery of primary care by an NP or PA. Services in Cartied clinics must be provided and furnished by a physician or by a PA, NP, nurse-midwito, fo other specialized nurse practitioner. Services and supplies are furnished as an incident to professional services. Part-time or intermittent visiting nurse care and related ‘medical supplies are provided given that the ciinic is located in a Health Manpower Shortage Area, the services are furnished by nurses employer by the clinic, and the services are furnished under a written plan of treatment to a homebound recipient. Other Laboratory and X-Ray Services Other laboratory and X-ray services are professional and technical laboratory and radio- logical services. As specified in 42 CFR 440.0(2-0), federal requirements for Medicaid ‘mandate that these services be: @ Ordered and provided by or under the Gicection of a physician or other licensed practitioner of the healing arts within the ‘scope of his practice as defined by state law or ordered and billed by a physician but provided by an independent laboratory; ‘© Provided in an office or similar facility other than a hospital outpatient department or alinio; and ‘© Provided by a laboratory that meets the requirements for participation in Medicare. In addition, the states can place limitations on ‘other laboratory and X-ray services." ‘Skilled Nursing Facility Services Skilled nursing facility (SNF) services are provided to individuals age 21 or older and do Not include services in institutions for tuberculosis or mental diseases (42 CFR 440,40(a)). These services must be needed on a daity basis and provided in an inpatient facity. Federal regulations require that the services be: © Provided by a facility or distinct part of a facility that is certified to meet the requirements for participation. These requirements include provider agreements, faclity certification, and facility standards; and '* Ordered by and under the direction of a physician, These services include services provided by any facility located on an Indian reservation and certified by the Secretary of Heatth and Human Services. Further, the requirements concerning Control of the utilization of Medicaid services Impact upon skilled nursing faciity services on such areas as certification and re-certiication of need for inpatient care, individuals written pian of care, ete. Eatly and Periodic Screening, Diagnosis and ‘Treatment Early and periodic screening, diagnosis and treatment (EPSDT) refers to screening and diagnostic services to determine physical or mental defects in recipients under age 21 and health care, treatment and other measures to ‘correct or ameliorate any defects and chronic conditions discovered (42 CFR 440.40(0)), ‘There are certain basic screening and treatment services that each state must provide as minimum (42 CFR 441.86). These services include: ‘© Heatth and development history screening Unciothed physical examination Developmental assessment Immunizations which are appropriate for age and health history ‘Assessment of nutritional status Vision testing Hearing testing Laboratory procedures appropriate for age ‘and population groups Dental services furnished by direct referral to a dentist for diagnosis and treatment for children three years of age and over ‘* Treatment for defects for vision and hearing, including eyeglasses and hearing aids; and ‘© Dental care needed for relief of pain and infections, restoration of testh and maintenance of dental heath ‘The state Medicaid agency may provide for any ‘other medical or remedial care specified as a Medicaid service even if the agency does not otherwise provide for these services to other recipients or provides for them in a lesser amount, duration or scope. wees Family Planning Services Family planning services and supplies are allowable for individuals of child bearing age as a means of enabling individuals to freely determine the number and spacing of their children. Atthough there are no federal regulations defining what family planning ser- vices a state can provide, provisional regulations are written which defined family planning services to be: _consuttation (including Counseling and patient education), examination, and treatment, furnished by or under the supervision of a physician or prescribed by @ physician; laboratory examination; medically approved methods, procedures, pharmaceutical supplies and devices to prevent conception; natural family planning methods, diagnosis and treatment for infertlty; and voluntary steriization. In addition, states may provide zany medically approved means other than abortion, for family planning purposes, i fumished by or under supervision of @physician or If prescribed by a physician. Abortions are specifically excluded from family planning services and states are prohibited from considering any abortion as being a family planning service. Voluntary sterlizations must be included among the range of family planning services offered by a state, Federal regulations require that the individual to be sterilized voluntarily gives informed written consent and that the individual must be at least 21 years of age at the time consent is obtained and must be mentally competent. Physicians’ Services Physicians’ services are covered whether provided in the office, the patient’s home, @ hospital, a skilled nursing facilty, or elsewhere. Physicians’ services must be within the scope of practice of medicine or osteopathy as defined by state law and by or under the personal supervision of an individual licensed under state law to practice medicine or osteopathy. Home Health Services Home heaith services are provided to a recip- jent at his place of residence which does not include a hospital, skilled nursing facility, or intermediate care factity ((CF) except for home health services in an ICF that are not required to be provided by the facility. Services pro- vided must be on physicians’ orders as part ot a writien plan of care that is reviewed by the physician every 60 days. Home health services include three mandatory services (parttime nursing, home heaith aide, medical supplies and equipment) and one optional service (physical therapy, occupational therapy, speech pathology and audiology services) (42 CFR 440.70). These Services are defined as follows: ‘© Part-time nursing - nursing that is provided on a parttime or intermittent basis by a home health agency. if there is no home neath agency in the area, services may be provided by @ registered nurse who is, currently licensed to practice in the state, receives written orders from the patient's physician, documents the care and services provided, and has had orientation to acceptable clinical and administrative record-keeping from a health department nurse; © Home Health Aide - home health aide service provided by a home health agency; ‘Medical Supplies and Equipment - medical supplies, equipment and appliances that are Suitable for use in the home; and Physical Therapy (PT), Occupational ‘Therapy (OT), Speech Pathology and Audi- ology Services - PT, OT, speech and hear- ing services provided by a home health agency or a facility licensed by the state to provide medical rehabiltation services. Home health services are provided to ‘categorically needy recipients age 21 and over ‘and to those under 21 only if the state plan provides SNF services for them. Nurse-Midwife Services ‘The Omnibus Reconciliation Act of 1980 mandates that payment must be made for nursemidwife services to categorically needy recipients (42 CFR 440.165). ‘These provisions require states to provide coverage for nurse-midwife services to the extent that the nurse-midwite is authorized to practice under state law or regulation, The Statute also requires that states offer direct reimbursement to nurse-midwives as one of the payment options. Nurse-midwives must be registered nurses who are either certified by an ‘organization recognized by the secretary or have completed a program of study and clinical experience that has been approved by the secretary. Nurse-midwite services are those concerned with management of the care of mothers and newborns throughout the maternity cycle. Pediatric Nurse Practitioner and Family Nurse Practitioner Services ‘The Omnibus Reconciliation Act of 1989 provides for the availabilty and accessibility of Services furnished by a centiied pediatric nurse practitioner (CPNP) or a certified family nurse practitioner (CFNP) to Medicaid recipients, These provisions require that CPNP and CFNP services be covered to the extent they are ‘authorized to practice under state law or segulation regardiess of whether they are supervised by or associated with a physician or ‘other heaith care provider. States are required 10 offer direct payment to CPNPs and CFNPs as one of their payment options.CPNP and CFNP certification requirements include a current license to practice as a registered nurse in the state, meet the applicable state requirements for quaification of pediatric nurse practitioners or family nurse practitioners, and be currently certified by the ‘American Nurses’ Association as a pediatric nurse practitioner or a family nurse practitioner. Federally Qualified Health Center and Other “Ambulatory Services Medicaid programs must offer Federally Qualified Health Center (FQHO) services and other ambulatory services offered by an FAHC under the provisions of the Omnibus Reconciliation Act of 1988. FQHC services are defined the same as the services provided by rural health clinics (RHC). The services include physician services, services provided by physician assistants, nurse practtioners, clinical psychologists, cinical social workers, and services and supplies incident to services normally covered if furnished by a physician or if incident to a physician's services. FQHOs are facilties or programs more ‘commonly known as Community Health Centers, Migrant Health Centers, and Health ‘Care for the Homeless, These centers may qualify for the provision of services under Medicaid as follows: + the facity receives a grant under sections £329, 390, oF 840 of the Pubic Heaith Service Act, ‘+ the Health Resources and Services Administration recommends, and the Secretary determines that the facility meets the requirements cf the grant; oF + the Secretary determines that a facility may Qualify through waivers of the requirements. Such a waiver cannot exceed two years. LIMITATIONS ON OPTIONAL SERVICES: ICFICE-MR Services Intermediate care facility (CF) services, other than in an institution for tuberculosis or mental diseases, refers to services provided in a facity that fully meets the requirements for a state license to provide on a regular basis, health-related services to individuals who do rot require hospital or SNF care but whose ‘mental or physical condition requires services that are above the level of room and board and can be made available only through institutional facilties. The facility must meet al the requirements to be Certified for Medicaid (42 CFR 440.150(a-b)). This optional service is provided by all 50 states. ‘Services for Individuals Age 21 and Under States may elect to provide two types of services for individuals age 21 and under: (1) skiled nursing facilty services and (2) inpatient psychiatric services, "Skilled nursing facility services for individuals under age 21° (42 GFR 4440,170(d)) are defined to be those services as spectied previously that are provided to recipients under 21 years of age. Inpatient psychiatric services for individuals under age 21 refer to services that are provided under the direction of a physician and are provided in an accredited facility or program (62 CFR 440.160). Federal regulations further specify certification of need, active treatment, and individual plans of care. Prescribed Drugs Prescribed drugs are simple or compound substances or micure of substances prescribed for the cure, mitigation, or prevention of disease, or for health maintenance that are prescribed by a physician or other licensed practitioner of the heating arts within the scope of their professional practice ‘as defined and limited by federal and state law (42 GFR 440.120). The drugs must be cispensed by licensed authorized practitioners ‘on a written prescription that is recorded and maintained in the pharmacist’s or practitioner's records, ‘States place limits on prescription quantities in different ways: number of prescriptions that can be filed in a certain time period, number of prescriptions that can be refiled in a certain time period, and quantity of each prescription. States further limit prescribed drugs by restricting the quantity of medication for a single prescription. Some of the ‘other limitst imposed on prescribed drug services are that brand name medicines and non-formulary medicines must be documented as ‘medically necessary’, refils must be filed by the same pharmacy as the original prescription and flu and pneumococcal vaccines are covered only for persons age 85 and over.Other Optional Services and Equipment. Clinic services are preventive, diagnostic, ‘therapeutic, rehabiltative or palliative items or services provided to an outpatient, by or under the direction of a physician or dentist, by @ faclity that is not part of a hospital but is ‘organized and operated to provide medical ccare to outpatients (42 CFR 440.90). hospital services refer to services {that are necessary to prevent death or serious impairment of the health of a recipient and ‘because of the threat to Ife or heaith necessitates the use of the most accessible hospital available that is equipped to furnish the services (42 CFR 440.170(6)). The services will be provided that such a hospital even If it does. ‘not meet the conditions for participation under Medicaid or the definition of inpatient or outpatient hospital services. Personal care services in a recipient's home reler to services prescribed by a physician in accordance with the recipient's plan of treatment and provided by an individual who is qualified to provide the services, supervised by a registered nurse, and not a member of the recipient's family (42 CFR 440.170(9). it should bbe noted that states which are granted a waiver under Section 2176 for home and community- based services (that an individual needs to ‘avoid insttutionalization) are given the latitude: 10 define personal care services differently, As of April 1, 1984, 42 states had been approved for Section 2176 waivers, Private duty nursing services refer to nursing services for recipients who require more individual and continuous care than is available trom a visting nurse or routinely provided by the nursing staff of the hospital or SNF (42 CFR 440,80). These services must be provided by a registered nurse or a licensed practical nurse under the direction of the recipient's physician. ‘The services must be provided in the recipient's ‘home, in a hospital, or in a SNF. Optometrists are included in the 42 CFR 440.60 category of ‘medical or other remedial care provided by licensed practitioners" They are licensed practitioners and provide medical, remedial care, of services other than physicians’ services, within the scope of practice as defined under the state law. Dental services (42 CFR 440.100) refer to diagnostic, preventive, or corrective procedures: provided by or under the supervision of a dentist. The services include treatment of: ©The teeth and associated structure of the oral cavity; and ‘© Disease, injury, or impairment that may affect the oral or general health of the recipient. A dentist is defined to be an individual licensed to practice dentistry or oral surgery. Podiatrists’ services are one of the services included under 42 CFR 440.60, ‘medical or other remedial care provided by licensed practitioners." These services include any ‘medical or remedial care provided by a podiatrist licensed and within the scope of practice as defined under state law, Chiropractors’ services are Included under 42 ‘CFR 440.80 ‘medical or other remedial care provided by licensed practitioners" Chiropractors’ services are defined to include only services that consist of treatment by ‘means of manual manipulation of the spine that the chiropractor is legally authorized by the state to perform. In addition to being licensed by the state, the chiropractor must also meet the standard issued by the Secretary of HHS. ‘These standards include age, education, and licensure standards. Prosthetic devices are defined by 42 CFR 440.120(c) to mean replacement, corrective, oF supportive devices prescribed by a physician or other licensed practitioner of the healing arts within the scope of practice as defined by state law. The devices must: © Articialy replace a missing portion of the body; ‘© Prevent or correct physical deformity or ‘malfunction; or Support a weak or deformed portion of the body. Physical therapy according to 42 CFR 440.110(a) refers to services prescribed by 2 physician and provided to a recipient by or ‘under the direction of a qualified physical therapist. To be a qualified physical therapist an individual must be licensed by the state, where applicable, and be a graduate of a program of physical therapy approved by boththe Council on Medical Education of the ‘American Medical Association and the ‘American Physical Therapy Association or its ‘equivalent. Physical therapy includes any necessary supplies and equipment. Occupational therapy (42 CFR 440.110(b)) refers to services prescribed by a physician and provided to a recipient by or under the Girection of a qualified occupational therapist. ‘A qualified occupational therapist is an individual who Is either registered by the ‘American Occupational Therapy Association ot who is a graduate of an approved occupational therapy program (by the Council on Medical Education of the American Medical Association) and engaged in the supplemental clinical experience required by the American ‘Occupational Therapy Association. ‘Occupational therapy services include any necessary supplies and equipment. ‘Services for inoividuals with speech, hearing and language disorders are provided as an optional service in 33 states. These services are diagnostic, screening, preventive, or corrective services provided by or under the direction of a speech pathologist or audiologist for which a patient is referred by a physician (62 CFR 440.110(¢)). it includes any necessary supplies and equipment. A speech pathologist or audiologist is an individual who has a contficate of clinical competence from the ‘American Speech and Hearing Association, has ‘completed the equivalent educational requirements and work experience necessary for the certtifcate, or has completed the academic program and is acquiring supervised ‘work experience to qualify for the cartticate, Diganostic services (42 CFR 440.130(a)) include medical procedures or supplies recommended by a physician, or other licensed practitioner of the healing arts, within the scope ‘of his practice under state law. ‘The services must enable the practitioner to identify the existence, nature or extent of illness, injury, or other heath deviation in a recipient. Screening services (42 CFR 440.120(b)) refer to the use of standardized tests given under medical direction in the mass examination of a designated population to detect the existence of one or more particular diseases. 10 Preventive sewices (42 CFR 440,130(c)) are those that prevent disease, disability, and other health conditions or their progression; services. that prolong life; and services that promote physical and mental health and efficiency. Preventive services must be provided by a physician or other licensed practitioner of the healing ans within the scope of practice under state law. Rehabiltative services (42 CFR 440.130(d)) are medical or remedial services for reduction of physical or mental disability and restoration of @ recipient to his best possible functional level ‘The services must be recommended by a physician or other licensed practitioner of the healing arts within the scope of his practice under state law. ‘Transportation services include expenses for ‘ransportation and other related travel expenses determined to be necessary by the agency to secure medical examinations and treatment for a recipient (CFR 440.170(a)). MEDICALLY NEEDY COVERAGE AND. UMITATIONS A state plan must specity that, as a minimum, categorically needy recipients are provided the mandatory services. Additionally, if'a state plan includes the medically needy, it must provide, as a minimum, the following services (42 CFR 440.220): ‘© Pronatal care and delivery services for pregnant women; ‘¢ Ambulatory services to individuals under age 18 and individuals entitled to institutional services; ‘© Home health services to individuals entitled to SNF services; and ‘© Ifthe state plan includes services either in institutions for mental diseases or in ICF-MRs, it must offer ether of the following to each of the medically needy group: the services contained in 42 CFR sections 440.10 through 440.50 and 440.165 (to the extent that nurse-midwives are authorized to practice under state law Cr regulations); and the services contained in any seven of the sections in 42 CFR 440.10 through 42 CFR 440.165. ‘The state can, in addition, provide any other services to the medically needy without beingbound by requirements pertaining to a minimum number of services or a mix of institutional and non-insttutional services. Furthermore, a state may offer one set of services for a certain medically needy group without being required to offer them to all the medically needy groups. COST SHARING States are permitted to require certain recipients to share some of the costs of Medicaid by imposing upon them such payments as enrollment fees, premiums, deductibles, coinsurance, copayments, or similar cost sharing charges (42 CFR 447.50) For states that impose cost sharing payments, the regulations specify the standards and conditions under which states may impose cost sharing, set forth minimum amounts and the methods for determining maximum amounts, and describe limitations on avaitabilty that relate to cost sharing requirements. With the passage of the Social Securty Amendments of 1972, states were empowered to impose ‘nominal cost sharing requirements on optional Medicaid services for cash assistance recipients, and on any services for the medically needy. Section 131 of the Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982 introduced major changes to Medicaid cost sharing requirements. States may now impose a nominal deductible, coinsurance, copayment, or similar charge upon both categorically needy and medically needy for any service offered under the state plan. Public Law 97-248, ‘TEFRA, has been in ettect since October 1982 and it prohibits imposition of cost sharing on ‘the following Services fumished to individuals under 18 years of age (oF up to 21 at state option); ¢ Pregnancy-related services (or, at state ‘option, any service provided to pregnant women); ‘© Services provided to certain institutionalized individuals, who are required to spend all of their income for medical care except for a personal needs allowance; ‘© Emergency services; Family planning services and supplies; ‘Services furnished to categorically needy HMO enrollees (or, at state option, services provided to both categorically needy HMO enrollees (or, at state option, services 1" provided to both categorically needy and ‘medically needy HMO enrollees). In addition, no more than one type of charge can be imposed on any service. While emergency services are excluded from ‘cost sharing, states may apply for waivers of nominal amounts for non-emergency services furnished in hospital emergency rooms, Such a waiver allows states to impose 2 copayment amount up to twice the current maximum for such services. Approval of a waiver request by HOFA is based partly on the state's assurance that recipients will have access to alternative sources of care, Medicaid Management Information System The Social Securty Amendments of 1972 authorized 80 percent federal matching to Bates for the costs of design, development, and installation or improvement of mechanized claims processing and information retrieval systems, and 75 percent for the costs of operating such systems, i the system is approved by the Administrator. ‘The MMIS is a general systems design that can be tailored by state Medicaid agencies to their ‘own particular needs so long as the system meets federally required minimum performance standards. The conceptual design includes six subsystems: recipient, provider, claims processing, reference file, surveillance and utilization review, and management and administration reporting. The first four subsystems work togetner with the overall ‘objective of processing and paying each eligible provider for every valid claim. The other two subsystems consolidate and organize data necessary for managing and controlling the Medicaid program. Medicaid Claims Processing Activity States handle the processing of Medicaid claims in different ways. There is variabilty in ‘who handies the claims for each service type. Claims processing activities for prescription drugs are handled by fiscal agents in 30 states, by States themselves in 16 states, and by a ‘combination of fiscal agent/state in four states. (1988)Medicaid Quality Contro! Each state agency must operate a Medicaid Quality Control (MGC) system designed to reduce erroneous expenditures by monitoring eligibility determinations, third-party lability activities, and claims processing (42 CFR 431,800(a)) MEDICAID PRINCIPLES OF REIMBURSEMENT From the inception of Medicare and Medicaid in 41965, there were two fundamental axioms related to provider reimbursement. The first ‘was that reimbursement be based upon reasonable cost or reasonable charges; basically the same philosophy used by private insurance carriers. ‘This, it was reasoned, would ensure equity of reimbursement and ‘adequate participation on the part of hospitals and physicians to ensure recipient access to quality mainstream medicine; Le., traditional, private, fee-for-service care, just as that enjoyed by privately insured citizens. The second axiom was freedom of choice; meaning that Medicare and Medicaid recipients would be free to choose from among many providers of care on the basis of convenience and satisfaction. The 1972 Social Security Amendments liberalized eligibility for Medicaid 10 include SSI recipients (cash assistance to poor elderly, blind, and disabled) and; at state ‘option, certain optionally categorically needy groups and certain medically needy people who would otherwise quaity fer the cash assistance programs i t were not for moderately excessive income or resources. ‘These policy decisions set the stage for explosive growth in Medicaid expenditures throughout the remainder of the seventies. Up through fiscal year 1981, Medicaid experienced double-digit annual growth rates, with hospitals and nursing homes representing three-quarters of total national expenditures. ‘Although Medicaid has been unquestionably successful in Improving access by the poor to health services generally (Davis and Schoen, 1978), it has been much less successful in ensuring access to mainstream medical care,’ ‘As gatekeepers to the rest of the health care ‘system, private physicians did not respond to the program as its architects had assumed. Part of this has to do with the welfare stigma of Medicaid clientele and part to do with R reimbursement rates for both Medicare and Medicaid falling behind those offered by private insurance carriers. Over 25 percent of the Nation's private practice physicians refuse to ‘eat Medicaid patients, and participation among key specialists such as OB-GYNs is even lower." In the nation's highly urbanized areas in which the majority of Medicaid recipients live, low office-based physician Participation rates drive large numbers ot Medicaid recipients to costly hospital-based settings for routine primary care; hence, higher costs per recipient. Quite inadvertently, the architects of the Medicaid program designed builtin reimburse- ‘ment incentives that would undermine its overall goal, access by the poor to quality mainstream medicine at reasonable costs. In the late seventies through 1980 states tried, with varying levels of success, to contain costs of the program through the use of more stringent eligibilty requirements, imposition of service cutbacks and limitations, tighter administrative controls, and postponement of increases in physician and pharmacy reimbursement. Although numbers of recipients deciined, the cost per recipient continued to rise sharply. It became obvious to HCFA that something had to be done about Medicaid cost-based provider reimbursement incentives for hospitals and nursing homes which had no real incentive to contain rising costs. Since the unit of payment was per diem, there was even an incentive to maximize utllzation so long as the Medicaid revenue played a useful role in the overall financial health of hospitals ang nursing homes. Further, Medicaid eligibility rules led physicians to institutionalize patients so they would be ‘eligible for needed services. The first significant legistative step to redress provider incentives came in 1980 with the Omnibus Reconciliation Act of 1980 (PL 96-499). The Act. replaced Section 249(a) of the 1972 Social ‘Security Amendments requiring Medicare-based retrospective cost reimbursement principles for nursing homes. States were freed to reimburse nursing homes on the basis of ‘reasonable and adequate to the costs which must be incurred by efficiently and economically operated facilities." Many states moved swiftly to implement prospectivereimbursement methodologies to curb inflation in nursing home costs, ‘The second significant step in reforming Medicaid provider reimbursement came with ‘of the Omnibus Reconciliation Act of 1981 (PL 97-35). Among other things, the Act, implemented by federal regulations on September 20, 1981, granted significant new ‘exibilty to the states in setting provider reimbursement policies for hospitals (Section 2173) and physicians (Section 2174) by relaxing the constraints which tied payments to Medicare retrospective cost reimbursement principles. States quickly began to adopt alternate payment methods tallored to their own unique needs. The Act gave states waiver authority to restrict freedom of choice (section 2175) and to eliminate the institutional bias towards institutional long-term care through home and community-based care (Section 2176). The Act also gave the states new flexibility to enter into prepaid service arrangements with non-federally quaiied HMOs and to impose certain copayments on service use by Medicaid recipients. The third significant piece of legisiation affecting Medicaid provider reimbursement policies is the Tax Equity and Fiscal Responsibility Act of 1982. TEFRA actually rescinded some of the fiexibiity given to the states through OBRA 81 by removing the authority given to the Secretary of DHHS to ‘grant waivers for capitation and prepayment systems to other than federally qualified HMOs ‘and restrictac the imposition of nominal ‘copayments by exempting from any copayment ceftain recipient types and services. The ‘TEFRA contained two other important provisions related to Medicaid reimbursement. The first was a requirement that the Secretary of DHHS recommend a system of prospective reimbursement for the Medicare program which might apply to the Medicaid inpatient reimbursement setting, The second was an expansion of Section 228 limitations on hospital charges from routine hospital costs per day to the cost per case, including ancilary costs. ‘Special adjustments are to be made for hospitals which have a cisproportionate load of low income or Medicare patients, and for psychiatric hospitals. Non-SMSA hospitals with Jess than 50 beds will be excluded from the ‘imitations. B Another step to reform Medicaid provider seimbursement is the Social Security Act Amendments of 1983. This Act mandates a three-year phase-in of a case rate prospective reimbursement system for Medicare that could also be adopted by state Medicaid agencies. ‘The Medicare Prospective Payment System (PPS) is based on a prospectively determined Tate for each patient according to age, sex and diagnostically-related grouping (DRG). To date, several state Medicaid programs have adapted the new Medicare PPS concept to their own hospital reimbursement system." Further changes to promote economy and to generate savings in the Medicaid programs will result from implementing section 2314 of the Deficit Reduction Act of 1984 and sections ‘9110 and 9509 of the Consolidated Omnibus Budget Reconciliation Act of 1985 (Pub. L 99- 272), enacted on April 7, 1986. These changes affect reimbursing providers for patient-care related capital costs by limiting the valuation of assets acquired as the result of changes in ‘ownership occurring on or after July 18, 1984, A recent legislative provision intends to clarity the flexibility granted State Medicaid payment systems for inpatient services, Section 9433 of OBRA 1984 (Pub. L. 99-509), provides that nothing in Title XIX of the Social Security Act shall be construed as authorizing the Secretary 10 limit the amount of payment adjustments that ‘may be under a Medicaid plan with respect to hospitals that serve a disproportionate number of low-income patients with special needs. This provision is intended to aid only hospitals meeting the States’ definition of a hospital that serves a disproportionate number of such patients, States are now not limited in the amount of a payment adjustment (e.g., an adc- on or a percent increase over a base payment amount) that may be granted to eligible hospitals for fiscal relief for specific costs incurred in providing care to these recipients.” Reimbursement Jn summary, the above discussion represents a historical perspective or context in which to consider now states altered their Medicaid provider reimbursement policies in recent years.Only nursing home, inpatient hospital, physician, outpatient hospital, free-standing ‘linios and prescription drug service reimbursement policies are included in this phase of the report. These services represent about 77 percent of all Medicaid expenditures for fiscal year 1992 NURSING HOME REIMBURSEMENT Expenditures for nursing home services is the largest and most rapidly growing component of national Medicaid outlays. From fiscal year 1982 through fiscal year 1992, Medicaid expenditures for nursing homes increased from $1239 billion to $32 billon (85% of total Medicaid spending). ICF-MR nursing expenditures continue to rise at a much higher rate than for SNF and ICF homes. Most state ‘Medicaid programs have departed from Medicare principles of reimbursement in favor of various forms ot prospective reimbursement where rates and rate increases are negotiated (or determined by formulas prior to each new fiscal year. The prospective methods are generally either facility specific negotiated rates Or class rates based on type of faciity, size, land location. Some states use a combination ‘of methods. (Other recent initiatives to contain nursing home Medicaid expenditures include restrictions in licensed bed capacity, more stringent patient assessment protocols for entry into homes, and emphasis on home and community-based care settings as an alternative to expensive institutional care. INPATIENT HOSPITAL ‘SERVICES REIMBURSEMENT Inpatient hospital services are the second largest component of Medicaid expenditures nationwide, accounting for $26.8 billion or 28.3, pporcent of Medicaid outlays in fiscal year 1992. Prior to the Omnibus Budget Reconciliation Act (OBRA) of 1981, states were generally com- pelled to use Medicare reasonable cost-based reimbursement principles unless authorized by DHHS to adopt an alternative method. Post-OBRA Environment By early 1986, only 16 states (17 percent of national inpatient expenditures) still used the Medicare retrospective cost-based method. ‘The other 34 states (83 percent of total inpatient expenditures) had moved to adopt either an alternative plan or an experimental system of inpatient reimbursement. Ten states aro using experimental systems based on diagnostic-related groupings (DRGs). Most of the other states using alternative systems have tended toward facity-specific budget review, rate of increase control and forms of prospective rate-setting, PHYSICIAN SERVICES REIMBURSEMENT Expenaitures for physician services are the fourth largest component of Medicaid expenditures, In fiscal year 19920, physician services accounted for $6.1 billion, or 7 percent of Medicaid expenditures nationwide, States have broad discretion within general federal guidelines regarding Medicaid reimbursement to physicians. Unlike Medicare, which uses the statutorily mandated customary, prevailing and reasonable (CPR) charge methodology, state Medicaid programs can use either the CPR method of a fee schedule approach; whichever is the lower, The Omnibus Budget Reconciliation Act of 1981 freed states from the CPR-based upper limit. States are now free to set physician Medicaid reimbursement payments at their discretion so long as they are ‘adequate and reasonable. “The CPR method used by Medicare limits reimbursement to the lowest of the following: a physician's actual charge, the physician's median charge in a recent prior period (customary), or the 75th percentile of charges in that same period (prevailing). Any prevailing charges at or under the 75th percentile criterion are considered ‘reasonable.* In some states, the 75th percentile is determined on the basis of physicians’ charges in the same specialty and sub-state region; in others, states use charge data from ali physicians regardless of speciaty or substate region. Finally, since 1976 an “economic index’ has been applied to limit the Fate of increases in Medicare prevailing rates. ‘Technically, Medicaid regulations refer to a “usual, customary and reasonablet (UCR) ‘method. Other than confusion over definitions, the UCR method and the CPR methods are the same.’ Within this framework, state Medicaic programs set physician reimbursement rates Using the Medicaid method or a fee schedule, whichever is the lower. Some states have delayed in updating physician charge profilesse artificially low economic indices, or simply elect to reimburse at below Medicare's 75th percentile of prevailing tothe point where they have in reality converted to a fee schedule. OUTPATIENT HOSPITAL, CLINIC ‘Outpatient hospital services refer to emergency rooms and hospital-based ambulatory care clinics. (*Clinics* refer to free-standing physician-supervised ambulatory care settings; ‘excluding rural health clinics.) Federal regula- tions specity only that Medicaid payments for ‘outpatient hospital services cannot exceed charges to Medicare. Below this ceiling, rates can be altered downward to reflect local conci- tions and preferences. There is flexibility to cifferentiate rates among emergency room care, specialized outpatient services and pri- mary care services. As with inpatient care, the trend has been for more and more states to abandon Medicare principles to reimburse out- patient hospital services in favor of alternate methods. PRESCRIPTION DRUG REIMBURSEMENT History: Federal Medicaid regulations dictate the method for reimbursing prescription drugs. Reimbursement is made on a retrospective, fee- for-service basis with payments limited to the lower of the pharmacys usual and customary charge or the estimated acquisition cost of the drug product plus an established dispensing {ee to cover the pharmacy's overhead and pro- fi. (Some states have experimented with ‘enrolling Medicaid eligibles in Health Mainte- nance Organizations under capitated payment contracts) in 1976, utilizing the authority to set ‘an upper limit for services available under Medicaid programs as provided under Section +1902(a)(80)(A) of the Social Security Act, the Health Care Financing Administration (HCFA), HHS implemented drug reimbursement rules at 45 CFR Part 19 pertaining to upper payment limits for Medicaid and other programs. Speci- fically, these regulations provided that the amount the Department recognized for drug reimbursement or payment purposes was pot to exceed the lowest ‘© the maximum allowable cost (MAC) of the rug, es established by HCFA’s pharmaceu: tical reimbursement board for certain mut source drugs (generic drugs), plus a rea- sonable dispensing fee; ‘© the estimated acquisition cost (EAC) of the drug (the price generally and currently paid by providers for a particular drug in the package size most frequently purchased by providers), as determined by the program agency, plus a reasonable dispensing fee; or © the providers’ usual and customary charge to the public for the drug: ‘@ the regulations provided that the MAC would not apply if the prescriber has Certified in his or her own handwriting that a certain brand of that drug is ‘medically necessary’ for the patient. ‘The regulations at 45 CFR Part 19 also established within HFA a pharmaceutical reim- bursement board (PRB). The PRB identified ‘muttiple-source drugs for which significant amounts of federal funds were expended and ‘was responsible for establishing the MAC for those drugs. The PRB sot the MAC at the lowest unit price for which the drug is widely and consistently available. in addition to limiting the level of payment for multiple-source drugs, the MAC program tended to promote substitution of lower cost drug products for brand name drugs. During its decade of implementation, @ number of problems and concerns were voiced about the MAC program by the pharmacies and the pharmaceutical industry. Specific concerns included: © quality of mutti-source drugs; © the interpretation “widely and consistently available" as related to the process used by the PRB in setting MAC limits; @ the adequacy of drug reimbursement; and ‘© problems and administering the MAC and EAC programs. in 1983, a departmental task force was. established to review the Department's drug reimbursement regulations at 45 CFR Part 19. ‘Subsequent to the Department's review process, an NPRM notice of proposed rule making was published on August 19, 1986. ‘The NPRM (61 FR 29560) proposed to remove the Department's rule at 45 CFR Part 19 that limited drug reimbursement under certain federal programs including Medicaid. The Department proposed three alternative approaches to the current Medicaid rules (42 CFR 447,331 through 447.334) regarding upper 15limits for drug reimbursement and invited public ‘comment on all three suggestions, as well a5 suggestions for alternatives which would improve any of the three recommendations. The three recommendations include: ‘© Pharmacists Incentive Program (PhIP) revisions to the current MAC programs © Competitive Incentive Program (CIP) Discussions outlining these proposats appear in the following pages under Federal Register Vol. 52 No. 147, Friday, July 31, 1987. FINAL RULE ON MEDICAID PRESCRIPTION DRUG REIMBURSEMENT ‘Current: On Friday, July 31, 1987, the Health Gare Financing Administration (HCFA), HHS, published a notice ofthe final rule for limits on payments for drugs in the Medicaid program. The regulations adopted in the rule become ‘effective on October 29, 1987 (62 FR 28648) Provisions of the final regulations. la this final rule, HCFA has attempted to (1) respond to public comments on the NPRM (51 FR 2956); (2) provide maximum flexibilty to the states in their administration of the Medicaid program; (8) provide responsible but not burdensome federal oversight of the Mecicaid prog/ram; and (4) take advantage of savings in the marketplace for muitipie source drugs. To accomplish this, HCFA is adopting a federal Upper limit standard for certain mutiple-source drugs based upon application of a specific formula. The upper limit for other drugs is similar in that it retains the EAC as the upper limit standard that state agencies must meet However, this standard is applied on an aggregate basis rather than on a prescription specific basis. State agencies are therefore encouraged to exercise maximum flexibility in establishing their own payment methodologies. (Gee Federal Reaister, Vol. 52, No. 147, Friday, July 31, 1987, p 28648) Multiple source Drugs: A muttiple-source drug is a drug marketed or Sold by two more manufacturers or labelets, or a drug marketed or sold by the same ‘manufacturer or labeler under two or more Gifferent proprietary names or both under a proprietary name and without such a name. 16 A specific upper limit for a multiple-source drug may be established if the following requirements are met: 1. Allof the formulations of the drug approved by the Food and Drug ‘Administration (FDA) have been evaluated as therapeutically equivalent in their ‘current edition of the publication, Approved Drug Products with Therepeutically Equivalent Evaluations, anc 2 Atleast three suppliers list the drug (which is classified by the FDA as Category A in its publication) in the current editions of pubiished compendia of cost information for drugs available for sale nationally. ‘The upper limit for a multiple-source drug for which a specific limit has been established does not anply it a physician certifies in his or her own handwriting that a specific brand is ‘medically necessary" for a particular recipient. The handwritten phrase ‘brand necessary* F n * oF "br ‘necessary* must appear on the face of the ‘prescription. The rule specficaly states that a ‘check-off box on a prescription form is not acceptable, but it does not address the use of two-line prescription forms. ‘The formuta to be used in calculating the aggregate upper limit of payment for certain muttiple-source drugs will be 150% of the least costly therapeutic equivalent that can be purchased by pharmacists in quantities of 100, tablets or capsules (or if the drug is not commonly available in quantities of 100, the package size commonly listed), or in the case of iquids the commonly listed size, plus a reasonable dispensing tee. Other Drugs: A rug described as “other drug" is (1) a brand name drug certified as medically necessary by the physician, (2) a muttiple-source drug not subject to the 150% formula; or (8) single- source drugs. Payments for these drugs must not exceed, in the aggregate, payment levels, determined by appiving the lower of: ‘© Estimated Acquistion Cost (EAC) plus reasonable dispensing fees or ‘© the provider's usual and customary charges to the general public.States may continue to use their existing EAC program, or adopt another method, as long as their aggregate expenditures do not exceed what would have been paid under EAC principles. Conctuston: ‘The Health Care Financing Administration (HCFA) publishes a list of those muttiple-source ‘drugs to which the upper limit payment formula will apply (see section ‘Upper Limits on Payments for Drugs, in the index). Revisions to the list will be provided through Medicaid program issuances "State Medicaid Manual - Part 6 Payment for Services" on a periodic basis. Any price revisions will be inoluded in these issuances The states are required in the rule to submit a state plan that describes their payment methodology for prescribed drugs. The rule does not prescribe a preferred payment method as long as the state's aggregate ‘spending in each catagory is equal to or below the upper mit requirements. States are also required to submit assurances to HCFA that the requirements are met. This new rule does not prescribe a preferred payment method for the states, but gives states the flexibilty to determine how they will pay for prescription drugs under Medicaid. As long as the state's aggregate spending is at or below the amount derived from the formula, the state is free to maintain its current payment program cf adopt other methods, States can alter payment rates for individual drugs, balancing payment increases for certain products with payment decreases for other drugs 50 that in the aggregate, the program does not exceed the established limit. With the establishment of upper limit payment maximums, some states may alter their current payment methodologies to comply with the established limitations. State programs will vary, depending upon whether or not state maximum allowable cost programs cover the same drugs Isted by HCFA. States with established MAC programs may remain unaffected if their MAC rates are already low, or they may have to make certain adjustments in their MAC levels to mest the federal aggreaate expenditure limits. States without MAC programs may develop a new payment 7 methodology to increase the use of lower cost generic drug products in order to keep within the upper payment limits, or may simply adopt HOFA's formula for listed drug products OBRA 1989 ‘The Omnibus Budget Reconciliation Act of 1989 brought numerous changes in the Medicare ‘and Medicaid programs. Changes in the Medicaid program include: Mandatory Coverage of Certain Low-Income Pregnant Women and Children States are required to expand eligibility under Medicaid to pregnant women and children under 6 years of age whose family income, beginning April 1, 1990, does not exceed 133 percent of the federal poverty level. Previous law had required states to provide Medicaid coverage only to pregnant women and infants under one year of age if family income, beginning January 1, 1990, did not exceed 100 percent of the federal poverty level. States are left with the option of providing such Coverage to children bom after September 30, 1989, who are 6 years of age but who have not attained 7 or 8 years of age, as selected by the State. The state option to provide medicaid coverage to pregnant women and infants under 1 year of age with family incomes that do not exceed 185 percent of poverty is not changed. The effective date of this law states is April 1 4990. States that have established eligibility at income levels greater than 133 percent of poverty may not change those income levels. States that have rot established the 123- percent income eligibility levels have until the first day of the first calendar quarter beginning after the close of the first regular session of the state legisiature that begins atte the date of the enactment of this Act to enact legislation before the state is considered to have failed to comply with this law. For a state that has a 2- year legislative session, each year of such ‘session is deemed to be a separate regular session of the state legisiature. Payment for Obstetrical and Pediatric Services A state pian, as of July 1 of each year, will not have met the requirements of this iaw, unless, by April 1 of the same year, the state submits to the Secretary an amendment to the stateplan that specifies the payment rates to be used for obstetrical services and, by specific procedure, for pediatric services under the plan in the succeeding period. The amendment must include any additional data that will assist the Secretary in evaluating the state’s comp- liance with the law, inciuding data relating to how rates established for payments to HMOs take into account such payment rates. ‘State Plan Amendments to Assure Adequate Payment A state plan, as of July 1 each year, will not have met the requirements of this law, unless, by April 1 of the same year, the state submits to the Secretary an amendment to the state plan that specifies the payment rates to be Used for obstetrical services and, by specific procedure, for pediatric services under the plan inthe succeeding period, The amendment ‘must also include any additional data that will assist the Secretary in evaluating the state's ‘compliance with the law, including data relating to how rates established for payments to HMOs take into account such payment rates. For purposes of this section: Obstetrical services means services relating to Pregnancy covered under the state plan provided by an obstetrician-gynecologist, ‘obstetrician, family practitioner, certified nurse midwite, or certiied family nurse practitioner and does not include inpatient or outpatient services or other institutional services; and Pediatric services means services covered under the state plan provided by a pediatrician, family practitioner, or certified pediatric nurse practitioner to children under 18 years of age and does not include inpatient or outpatient hospital services or other institutional services. Early and Periodic Screening, Diagnostic and ‘Treatment (EPSDT) Services. Expanded Definition of s Early and periodic screening, diagnostic, and treatment (EPSOT) services are expanded and ‘more fully defined. Under the revised definition, EPSDT services mean the following items and services: 1, Screening services provided () at intervals that meet reasonable standards of medical and dental practice, as determined by the state after consultation with recog- nized ‘medical and dental organizations involved in child health care, and (i) at such other intervals, indicated as medically necessary, to determine the existence of certain physical or mental illnesses or conditions; ‘and that shall at a minimum include: @ — acomprenensive health and development history (including an assessment of both physical and mental heath development); (a.comprenensive unclothed physical exam; (i) appropriate immunizations according to age and health history; (W) laboratory tests (including lead blood level assessment appropriate for age and risk factors); and (W) heath education (including anticipatory guidance). . Vision services that are provided ()) at intervals that meet reasonable standards of ‘medical practice, as determined by the state after consultation with recognized medical ‘organizations involved in child health care, and (i) at such other intervals, indicated as medically necessary, to determine the ‘existence of a suspected Illness or ‘condition; and that shall at a minimum include diagnosis and treatment for defects in vision, including eyeglasses. Dental services that are provided () at intervals that meet reasonable standards of dental practice, as determined by the state after consultation with recognized dental ‘organizations involved in child health care, and (i) at such other intervals, indicated as medically necessary, to determine the exis- tence of a suspected illness or condition; and that shall at a minimum include relief of pain and infections, restoration of teeth, and maintenance of dental heaith, Hearing services that are provided (j) at intervals that meet reasonable standards of medical practice, as determined by the state after consultation with recognized medical ‘organizations involved in child heaith care, and {i) at such other intervals, indicated as medically necessary, to determine the ‘existence of a suspected illness or ‘condition; and that shall, at a minimum, include diagnosis and treatment for detects, in hearing, including hearing aids.6, Such other necessary health care, diagnostic services, treatment, and other measures described under this law to correct or ameliorate defects and physical ‘and mental illnesses and concitions discovered by the screening services, whether or not such services are covered under the state pian. Nothing in this law isto be construed as limiting providers of EPSDT services to providers who are qualified to provide all of the items and services described here or as preventing a provider that is qualified under the plan to furnish one or more (but not all) of such items or services from being qualified to provide such items and services. Payment for Federally Qualfied Health Center Services Coverage for medical assistance under the Medicaid program is expanded to include the cost of federally qualified health center services and any other ambulatory services offered by a federally qualified heath center that are otherwise included in the state plan. A summary of federally qualified health center services is referenced above under the “Characteristics of Benefits Provided. Medicare Buyin for Certain Working Disabled ‘State Medicaid plans must make provisions for making medical assistance available for payment of Medicare cost-sharing for otherwise qualified disabled and working individuals Eligibility: Quaiified disabled and working individual is defined as an individual: (1) who {s entitled to enroll for hospital insurance benefits under part A of Madicare; (2) whose income (as determined under the supplemental security income program) does not exceed 200 percent of the official federal poverty line applicable to a family of the size invoived; (3) whose resources (as determined under the supplemental security income program) do not exceed twice the maximum amount of resources that an individual or a couple (in the case of an individual with a spouse) have ang ‘obtain benefits for supplemental security income benefits; and (4) who is not otherwise eligible for medical assistance under the Medicaid law. 9 Premium Payments A state Medicaid pian may provide that a qualtied disabled and working individual whose income exceeds 150 percent of the official poverty line be charged a premium (expressed as a percentage of Medicare cost-sharing otherwise provided with respect t0 the individual) according to a sliding scale under which the percentage increases from 9 to 100 percent, in reasonable increments (as determined by the Secretary). Required Coverage of Nurse Practitioner Services Medical assistance under Medicaid is expanded to Include the services furnished by a certified pediatric nurse practitioner or Certified family nurse practitioner (as defined by the Secretary) that these nurse practitioners are legally authorized to perform under state law (or state regulatory mechanism) whether or not these nurse practitioners are under the supervision of, or associated with, a physician or other health care provider. This amendment is to be effective with respect to services fumished by a certified pediatric or certified nurse practitioner on or after July 1, 1880. Nursing Home Reguiations A moratorium is established on regulations ‘setting standards for long term care facilities subject to reimbursement under Medicare or Medicaid (64 E.R. 5315). These regulations, originally to be effective on Aug. 1, 1989, are ‘ot to become effective prior 10 Oct. 1, 1980. readmission Screening/Annual Screening Requirement for Mertally il and Mentaly Retarded individuals, ‘The Secretary is to issue proposed regulations (criteria to be used by states in their review functions) within 90-days of enactment. Prior law called for these criteria to be developed by October 1, 1988. Medicaid Coordination with WIC Program A state plan must provide for coordination of Medicaid program operations with the state's ‘operations under the speciat supplemental food rogram for women, infants, and children (the WIC Program), ‘The state plan must also provide for timely notification of all individuals i the state who are determined to be eligible for ‘medical assistance and who ate pregnant‘women, breastfeeding or postpartum women, or children below the age of 8, of the availabilty of benefits furnished by the WIC Program, and for referring any such individual to the state agency responsible for administering the program. ‘These amendments are to take effect on July 1, 41990, without regard to whether regulations to carry out the amendments have been promulgated. Demonstration Projects: Extending Medicaid to Pregnant Women and Chidren Not Otherwise Qualified to Receive Medicaid In order to allow states to develop and carry ‘out innovative programs to extend health insurance coverage to pregnant women and children under age 20 who lack insurance anc to encourage workers to obtain heaith insurance for themselves and their children, the Secretary shall enter into agreements with several states for the purpose of conducting demonstration projects to study the effect on access to health care, private insurance coverage, and costs of health care when such states are allowed to extend benefits under Medicaid, under altematives otherwise ‘authorized under the Medicaid law (enrollment in family option of employer of state employee pian, in state uninsured pian, or in an HMO), to pregnant women and children under 20 who are not otherwise qualified to receive benefits under the Medicaid program. Project Requirements Each state applying to participate in the ‘demonstration projects must assure the Secretary that eligibilty will be limited to pregnant women and children who have not attained 20 years of age who are in families with income below 185 percent of the federal poveny line. Each demonstration project shall ‘be conducted for a period not to exozed 3 years, The Secretary must further provide in Conducting demonstration projects that if one (or more of such demonstration projects utilzes ‘employer coverage as otherwise allowed under the Medicaid law, that such project must require an employer contribution. Where deemed appropriate, the Secretary may waive the otherwise applicable ‘statewide™ requirements under the Medicaid law. 20 Premiums In the case of pregnant women and chiidren eligible to participate in such demonstration projects: (1) there shall be no premium charged if their family income level is below 100 percent of the official federal poverty level applicable to a family of the size involved; and (2) if their income is between 100 and 185 percent of the federal poverty level, there shat! 'be a premium equal to (A) an amount based on a sliding scale relating to income, or (B) 3 percent of the family's average gross monthly earings, whichever is less. Evaluation and Report For each demonstration project conducted, the Secretary must assure that an evaluation is conducted on the effect of the project with respect to: access to heaith care; private heath insurance coverage; costs with respect to heatth care; and developing feasible premium and cost-sharing policies, The Secretary must submit to Congress an interim report containing a summary of the evaluations conducted not later than January 1, 1992, and a final report containing such summary together with further recommendations as the Secretary may determine appropriate not tater than January 1, 1994. Limit of Exoengitures {In conducting demonstration projects, the Secretary must limit the amount of the federal share of benefits paid and expenses incurred under the Medicaid jaw to $10,000,000 in each of fiscal years 1990, 1991, and 1992. ‘Study: Institutions for Mental Diseases ‘The Secretary must conduct a study of: (A) the implementation — under current provisions, reguiations, guidelines, and regulatory practices under the Medicaid law -- of the exclusion of coverage of services to certain individuals residing in institutions for mental diseases; and {@) the costs and benefits of providing services Under the Medicaid program in public sub- ‘acute psychiatric facilties that provide services 10 psychiatric patients who would otherwise require acute hospitalization, By not later than October 1, 1990, the Secretary ‘must submit a report to Congress on the study and must include in the reportrecommendations respecting (A) modifications. in such provisions, regulations, guidelines, and practices, i any, that may be appropriate to ‘accommodate changes that may have occurred since 1972 in the delivery of psychiatric and ‘other mental health services on an inpatient basis to such individuals; and (B) the continued coverage of services provided in sub-acute psychiatric facities under the Medicaid law. {Any determination by the Secretary that Kent ‘Community Hospital Complex and Saginaw ‘Community Hospital in Michigan is an institution for mental diseases, for purposes of the Medicaid law, shall not take effect until 180 days after the date Congress receives the report required under this section) Hospice Payment for Room and Board Medicaid payments for hospice care must be ro lower than amounts paid for such care under part A of the Medicare program. An exception willbe allowed in the case of hospice care furnished to an individual who is a resident of a skilled nursing faciity or intermediate pursing facility and who would be eligible under the pian for skilled nursing facility services or intermediate care facility services if he or she had not elected to receive hospice care. Under the exception, an addtional amount shall be paid to take into account the room and board furnished by the faciity, equal to at least 95 percent of the rate that would have been paid by the state under the plan for facility services in that facility for that individual. This amendment is to apply to services fumished on or after April 1, 1990, without regard to whether or not final regulations have been promulgated to implement such amendments, OBRA 1950 During the 1990 legislative year, Congress Considered a number of proposals designed to reduce and control federal and state expenditures for prescription drug products Provided to Medicaid patients, Among the bills under consideration were 8.2605, Pharmaceutical Access and Prudent Purchasing Act, and $ 3029, Medicaid Ant-Discriminatory Drug Act, sponsored by Senator David Pryor (O-AR), and H.R.5589, Medicaid Prescription Drug Fair Access and Pricing Act, sponsored by Representatives Ron Wyden (D-OR) and Jim an Cooper (D-TN). Following the introduction of the above legistation, several pharmaceutical ‘manufacturers voluntarily offered rebates to the states in exchange for open access for their products and the Pharmaceutical Manufacturers Association proposed a set rebate amount in exchange for open formularies, In the course of the budget debate, the Office of Management and Budget (OMB) incorporated various components of the above proposals into the budget bil, The Omnibus Buciget Reconciliation Act of 1990 (OBRA 'S0). The resulting Public Law 101-508, enacted November 5, 1990, requires a pharmaceutical ‘manufacturer to enter into and have in effect a rebate agreement with the federal government for statas to receive funding for pharmaceuticals dispensed to Medicaid recipients (except that, the Secretary of HHS may authotize a state to enter directly into ‘agreements with a pharmaceutical manufacturer). Pharmaceutical manufacturers must agree 10 provide rebates to al state Medicaid agencies, stfective January 1, 1990, for their products to be eligible for inclusion in Medicaid programs. The requirement for rebate agreements does ‘not apply to the dispensing of a single-source Or innovator mutiple-source drug F the state has determined that the drug is essential, rated 1-A by the FDA, and prior authorization is obtained for the exception. Existing rebate agreements quaify under the law the state agrees to report all rebates to HHS and the agreement provides for a minimum aggregate rebate of 10% of the state's expenditures for the manufacturer's products Rebate Calculation For single-source and innovator mutiple-source products, manufacturers are to pay the following rebates quarterly to each state agency: 1961 (0¥) — greater of 12.5% of average manufacturer price (AMP) or difference between AMP and ‘Best Price’, not to exceed 25% of AMP (AMP and Best Price are defined below) $982 (CY) — same as 1991, except the rebate percentage is capped at 50% of AMP1993 (CY) — greater of 15% of AMP or ‘ifference between AMP and Best Price (no maximum cap) 1994 (CY) — same as 1993 For norinnovator (genetic) multiple source products, the rebate is 10% for years 1991-93 ‘and 11% for 1994. An additional rebate for all drugs is provided to the extent the price rise (increase in AMP) exceeds the Consumer Price Index-Urban (CPI-U); for 1991-89 the increase will be calculated on a per-product basis, and for 1994 and beyond, on a productine basis. ‘AMP is the average price paid by wholesalers for products distributed to the retail class of trade. “Best Price’ is the lowest price paid by any purchaser (exclusive of depot prices and single-award contract prices as defined by any federal agency) and includes products with special packaging, labeling, or identifiers, Under the Omnibus Budget Reconciliation Act ‘of 1990, state Medicaid formuiaries must include all prescription products of manufacturers who have signed drug rebate agreements, States may, however, require physicians to request and receive official permission before a particular product can be dispensed. This procedure is called Prior ‘Authorization ot Prior Approval States may not operate "Prior Approval’ plans unless the state provides for a response withit 24 hours of a request and provides for a 72- hour emergency supply of the medication. States may not restrict a newly approved pharmaceutical product until six months after approval. States may restrict all drugs in a therapeutic class, quantities per prescription, and refils as necessary to discourage waste, States may exclude or restrict coverage of products: ‘© fits use is not for a medically accepted ation or if the product is subject to other restrictions of the law. ‘© That are used for anorexia, weight gain, fertility, hair growth, cosmetic effect, symptomatic relief of cough or cold, or for cessation of smoking, ‘© That are vitamins and minerats (except prenatal vitamins and fluoride preparations) (or non-prescription drugs. 22 ‘© That require tests or monitoring services to be purchased exclusively from the manufacturer or his designee. ‘# That are designated non-effective or are in the class of barbiturates or benzodiazapines. ‘The Congressional intent for the prior authorization provision was not to encourage the use of such programs, but rather to make them available to the states for the purpose of controlling utilization of products that have very ‘narrow indications or high abuse potential. Prior to OBRA ‘26, all but seven states used prior authorization for some products. Though the prior authorization provisions were nat intended to restrict the availability of medication for Medicaid patients, many states have signaled their intention to continue prior authorization programs to the degree that they could have the effect of continuing to deny Patients access to needed medications. Both patient and provider groups, as well as state legislators, have expressed their concems about these restrictions to Department of Health and Human Services Secretary Louis Sullivan. AAs of this writing, thinty-cight states report the ‘establishment of prior authorization programs and have plans 10 apply it to a select number of drugs. Some states will do so only after their Drug Utilization Review (DUA) program has identiied areas of therapeutic concem. if states attempt to use prior authorization as a substitute for the now-prohibited restrictive drug formutaries, t could lead to significant legal and legislative engagements in the months and years ahead. Medicaid rebate reguiations must bbe promulgated at HCFA and were due to be published by September 1991, however, due to the moratorium on new regulations, the issuance of these regulations is not likely until October 1, 1992. Pharmacy Reimbursement ‘The law does not provide any set-aside monies or allocations to increase pharmacy reimbursement. Until 1985, however, the {federal government cannot modify the formula ‘on reimbursement limits to reduce the limits for outpatient prescriptions under the Maximum Allowable Gost program. States must comply‘with similar regulations on reducing imits or Gispensing fees. Drug Use Review Drug Use Review (DUR) can be defined as a structured and continuing program that reviews, analyzes, and interprets pattems of ‘drug usage in a given health care environment against predetermined standards, ‘The two primary objectives of DUA systems are (1) to improve quaity of care; and (2) to assist in containing heath care costs. While there is ‘a general belief that DUR is cost beneficial, tis. ficult to isolate concrete evidence that supports this view. The primary issue facing Medicaid DUR programs is whether or not the ‘systems currently in place (or envisioned) meet the two objectives outlined above. By January 1, 1992, state plans must establish a Drug Use Review (DUR) program consisting of prospective and retrospective components. as well as components to educate physicians ‘and pharmacists. on common drug therapy problems and assessments of whether usage ‘complies with predetermined standards. Some state Medicaid programs have been siowed in their development of the DUR program by the moratorium on the issuance of new regulations. AAs of this writing, federal implementation of regulations for DUR have not been completed by the Office of Management and Budget clearance process, but are due to be published in September 1992. Prospective DUR is to be conducted at the point of sale (POS) before delivery of a medication by the pharmacist to the Medicaid recipient or caregiver to such individual, The state shall establish standards for counseling patients and will require the pharmacist to offer to discuss matters which, in the exercise of the pharmacist's professional judgement are ‘deemed significant, including the following: ‘© Name and description of the medication ‘© The route of administration, dosage form, dosage, and duration of therapy ‘© Special directions and precautions for preparation, administration and use by the patient ‘® Common severe side or adverse effects or interactions and therapeutic contraindications that may be encountered, 23 including their avoidance, and the action required if they occur. ‘© Techniques for self-monitoring prescription therapy ‘© Proper storage Prescription refll information, and © Action to be taken in the event of a missed dose ‘State law must also require pharmacists to make a reasonable effort to obtain, record, and ‘maintain at least the following information for each Medicaid recipient: ‘¢ Name, address, telephone number, date of birth (or age) and gender ‘© Individual history where significant, including disease state or states, known allergies and ‘drug reactions, and a comprehensive list of medications and relevant devices ‘* Pharmacist comments relevant to the individua’s pharmaceutical therapy Retrospective therapy is to be ongoing, based ‘on compendia standards and medical iterature, and to include remedial strategies for ‘educational outreach through a wide range of interventions. Each state plan shall establish a Drug Use Review board consisting of no more than 51% physicians and at least one third pharmacists. Studies and Repons A number of reporss, studies and Gemonstration projects are mandated by the new law: ‘An annual report to Congress Ten statewide demonstration projects to evaluate DUR ‘© Five statewide demonstration projects 10 evaluate payment for cognitive pharmacy services ‘* A study of pharmaceutical purchasing and biling activties of hospitals and organized health-care settings ‘¢ An annual report of prices charged for medicines sold to the VA, other federal purchasers, retail and hospital pharmacies, purchasing groups and managed care entities ‘© A study on the adequacy of current reimbursement rates to providers # A study on methods to encourage Medicare providers to negotiate discounts for suppliersElectronic Claims States will be granted a 90% match of funds to encourage the development and implementation of POS electronic claims- management systems. Veterans Health Care Act of 1992 ‘The drug pricing provisions of the Veterans Heatih Care Act of 1992 (PL 102-585) amend the Medicaid drug rebate statute and also establishes additional discount programs applicable to the Public Heatth Service (PHS), Deparment of Veterans Affairs (DVA) and Deparment of Defense (DOD). The Act was signed into law by President George Bush on November 4, 1992, The keystone of the law is the prohibition ‘against federal payment (from Medicaid, DVA, DOD, PHS, the indian Heath Services, and PHS-funded entities) for a manufacturer's ‘covered outpatient drugs unless the manufacturer meets the following three sets of discount and rebate requirements: 1. Medicaid — the Act amends the OBRA ‘90 drug rebate statute's provisions to exclude the prices of certain entities from the definition *best price." The Act also modifies ‘existing provisions to exclude the prices of certain entities relating to the calculation of the basic rebate, confidentiality, manufacturer terminations, and reports to Congress. 2. PHS Entities — the Act establishes ‘mandatory price discounts for a variety of clinics that receive funding under the Public Health Service Act and other ‘covered 3, DVA and Other Federal Agencies — the Act requires manufacturers to enter into a master agreement with the Secretary of DVA. Revisions to Medicaid Rebate Calculation For coverage of an outpatient drug under Medicaid after January 1, 1993, a manufacturer must have entered into rebate and discount ‘agreements with the Secretary of Health and Human Services for Medicaid and PHS entities, ‘a8 well as the above mentioned DVA master agreement. The Act revises the formula for calculating the Medicaid basic rebate for single ‘source and innevator multiple source drugs. ‘The Medicaid rebate statute under OBRA ‘90 called for manufacturers to pay a quarterly rebate to the state equal to the greater of 15 percent of the product's average manutacture price (AMP) or AMP less best price. The new law requires manvtacturers to pay @ ‘quarterly rebate to each state agency based on the adjusted basic rebate calculation for specified periods as follows: October 4 December 31, 1983 ‘greater of 15.7% of AMP or AMP minus best price. 1998 (CY) ~ greater of 15.4% of AMP or AMP minus best price 1995 (CY) ~ greater of 15.2% of AMP or AMP ‘minus best price Beginning in 1996 — greater of 15.1% of AMP or AMP minus best price ‘The best price definition established under (OBRA ‘20 is further amended to exciude prices from the Indian Health Service, DVA, DOD, PHS, stale veterans homes, state pharmaceu- tical assistance programs, covered PHSA entities and Federal Supply Schedule prices. OBRA 1983 President Clinton signed the Omnibus Reconciliation Act of 1983 (PL 103-213) on ‘August 10, bringing to a close one of the most contentious Congressional batties in years. House and Senate conferees agreed on a $496, bilion deficit reduction package which included $7.1 billion in Medicaid cuts from projected expenditures over the next five years, The law also includes several important modifications to the Medicaid drug rebate provisions (Section 19602). In summary, the new act repeals: + the antiformulary provision of OBRA “20; + the sic month window" for new drug products; and, + the weighted average manufacturer price (WANP) calculation that would have determined inflation-related rebates beginning in 1994, With these changes, a state Medicaid program can restrict coverage for a drug product through a formulary if based on official labeling or information in appropriate medical compendia, ‘the excluded crug does not havea significant, clinically meaningful therapeutic advantage in terms of safety, effectiveness or clinical outcome of such treatment’ over other drug products. Under OBRA ‘93, excluded drug products must be available through prior authorization. Prior to the passage of OBRA “83, Medicaid programs maintained open formularies which guaranteed Medicaid recipients access to medicines, but subject to prior approval if the state had such a program. (BRA ‘93 eliminates the six-month window. ‘The new act no fonger contains language that requires new drug products be covered for six months after FDA approval without being ‘subject to prior authorization or other restrictions. State Medicaid programs may now impose prior authorization controls with respect to new drugs during the first six months following approval. OBRA ‘90 had explicitly prohibited states from establishing Medicaid formularies, and prohibited states from subjecting drugs to prior authorization ‘programs for sic months after approval The formula for computing the inflation-based ‘additionat Medicaid drug rebate was altered to retain the method for use before 1994, when ‘OBRA ‘90 was to begin calculating additional rebates based on the weighted average price of a manufacturers total line of products. ‘OBRA ’93 reinstates the calculation of additional rebates on a drug-by-drug basis. ‘The new law also prohibits physicians with certain financial relationships with an entity” from referring patients to the entity for designated services and items including outpatient prescription drugs. ‘These provisions are effective October 1, 1999, * Davis & Schoen, Health and the War on Poverty, A Ten Year Appraisal; Brookings Institution, 1978, * Health Care Financing Program Statistics, 1986, HCFA 93249. 25NPC - 1993, ‘SUMMARY OF MEDICAID DEMONSTRATION PROJECTS. ‘Geographic Delvery state ‘Area Eligibles Benefits ‘System iS COBRA ‘89 “Sec. 6407...10 extend Medicaid eligibility to pregnant women and children.” Michigan Statewide Children through Primary Care, Blue Cross/Blue age 13 in households ambulatory ser- Shield providers, up to 185% of FPL, not vices, including BCBS Pharmacy otherwise eligible outpatient sub- PPO for Medicaid stance abuse and prescribed drugs Florida Volusia County Children in school, i Comprehensive Mixed model households with incomes commercial HMO below 185% of FPL HMO benefit Maine Statewide Children age 6-19, in Similar to Medicaid Medicaid households with incomes except no LTC, Dolow 125% of FPL pregnancy or Transition coverage targeted case 425-185% of FPL for management up to 2 years OBRA “90 "Sec. 4745...0 expand Medicaid coverage to certain low income families." Maine Statewide ‘Adutts (age 20+) below Same as Medicaid Primary Care 100% of FPL. Transition (No Long Term, Case Manage- coverage for up to 12 Care) ment System months uo to 180% of FPL South Carolina Hoary & Persons employed by small Similar to Medicaid Primary care Marion Counties firms, incomes below 150% doctor serves as ‘of FPL, where no health gate keeper coverage in past year Washington Spokane County Persons in families below Basic ambulatory HMO and PPO 150 of FPL who don't and hospital care, otherwise qualify for Medicaid. Employers can buy in for employees and their dependents 26 family planning, hospice, nursing facilityNPC - 1993 UNDER OBRA ‘89 AND ‘90 Projected Current Status: 8-Year Total Financing ‘Maximum ‘State Date/Current Budget Method Non- Payment Method Enrotiment Enrolment ‘Al Funds/Federal Federal Funds ———— OBRA ‘89 *Sec. 6407....10 extend Medicaid eligibility to pregnant women and children.” State purchases “Caring 1,000 Bogan 11/91, Curent $14.6 M/ Private contri- Program for Children enrollment is 1,117 $6.0 M Federal butions of up to coverage from Blue Cross, December enroiiment ‘$2 Million per Premium is $29.50/mo. expected to be 1,441 year. No state Providers are paid FFS Waiver approval ex- funds. @ BCBS rates, pected soon, state pays HMO premium 7,400 Waiver approved $17.1 M/ State appropriations ‘of $59/month. Between 3/19/92. Current 39.4 M/Federal and local contr-130% = 180% of FPL, En- enrolment is 4,500. butions to premium roliees pay $16/mo, payment rescue fund Medicaid providers paid 41,050 Waiver approved $18.9 M/ State appro- FS @ Medicaid rates, e/ia/at. Current $9.8 MiFederal priations Rate @ $66.00/mo. enrollment is 5,400 OBRA '90 "Sec. 4745..t0 expand Medicaid coverage to certain iow income families." Medicaid providers paid 7,600 Implementation without $41.1 M/ State appro- FFS @ Medicaid rates, PCCM 10/1/90 with $25.3 MiFederal —_priations. plus monthly case Maine Health Program. management fee. Enrollment closed 2/54 Rate @ $180/mo. @ 8,000. Current enrollment is 3,000 Below 100% of FPL: 4,800 Implementation 10/1/32 $8.1 M/S5.6 M Premiums (paid by - Employer pays premium Enrollment begins Federal ‘employer and 400% t0 150% of FPL: ais2 employee) of $1.8 - Enrollee pays 25% of million are the state premium. Premium is $39/mo. share @ 28.72% of for ingividuals, $89/mo. for total cost farilies Prepaid Capitation 3,200 Implementation 10/1/82 $12.7 M/ Premiums (paid by $7.0 M/Federal employer and employee) are the state share @ 45% of total cost tional Academy for Stato Meath Policy (VKS) 8/1/82 27MEDICAID VOLUNTARY CONTRIBUTIONS AND PROVIDER-SPECIFIC TAX AMENDMENTS OF 1991 The mounting costs of federal mandates to cover more of the poor through Medicaid and budget shortfalls, compounded by a sagging economy, has forced states to saek new revenue sources. A financing mechanism some states employ to generate additional revenues are voluntary contributions (or donations) and taxes on providers. ‘The federal government now finances approximately 55% of total Medicaid spending by matching the amount of money that states Put into the program. A state's match rate ranges from 50% to 83%. The use of donations and provider taxes increases state money available for services under Medicaid, and allows the state to finance par of their state match. Federal officials have characterized state donation and tax programs as revenve schemes designed to increase federal funding without adding any real state ‘money and without enhancing services. As of this writing, 19 states use donations to boister their Medicaid funds, while another 19 use Provider taxes. ‘On December 12, 1991, President Bush signed into law the Medicaid Voluntary Contribution and Provider-Specitic Tax Amendments of 1991 (P.L 102-234). The new law establishes ‘guidelines under which states would be Permitted to use voluntary donations and taxes (on health care providers as part of their ‘matching funds for the Medicaid program. But, it also sharply restricts federal matching Payments to the state Medicaid programs. ‘The law establishes a transition period during which states that had tax or donation’ programs could continue those programs. The Health Care Financing Administration has received an exemption from the moratorium on Rew regulations, and anticipates that implementing reguiations will be promulgated by September 1892. Provided below is @ summary of the major legislative provisions of the law. OVERVIEW ‘The Medicaid Voluntary Contribution and Provider Specific Tax Amendments of 1991 28 amend provisions of Title XIX of the Social ‘Security Act and establish new limitations on Federal Financial Patticipation (FFP) when states receive funds donated from providers and revenues generated by certain health care related taxes. In general, under the new law a reduction in FEP will ocour if states receive donations made bby, or on behalf of health care providers, The law also establishes a definition of the types of health care related tax revenues states are ‘permitted to receive, without reduction in FFP. ‘States which have received provider donetions and taxes which are not permitted by this law ‘may continue to receive them for a limited time, without a reduction in FFP. The law ‘applies to donations from providers and related entities, and to health care related taxes. It does not affect the treatment of donations from other entities not related to providers and the receipt of revenues from generally applicable taxes, ‘The provisions of the new taw affecting taxes, donations and disproportionate share hospital (OSH) payments apply to all 50 states and the District of Columbia, except Arizona, which ‘operates its Medicaid Program under a waiver ranted under section 1115 of the Social ‘Security Act ‘The law applies to donations from providers and related entities, and to health care related taxes. It does not affect the treatment of donations from other entities not related to providers and the receipt cf revenues from generally applicable taxes. USE OF PROVIDER RELATED DONATIONS AND HEALTH CARE RELATED TAX REVENUES General Rule: Effective January 1, 1992, before calculating the amount of Federal Financial Participation (FFP), cenain revenues received by a state will be deducted from the State's expenditures for medical assistanes. ‘The revenues to be deducted are as follons: ‘+ Donations made by health care providers and entities related to providers (except for bona fide donations and, subject to a limitations, donations made by providers for the direct costs of outstationed eligibility workers)‘= impermissible "Health Care Related Taxes* + Until October 1, 1995, “Permissible Heatth- Care Related Taxes" that exceed specified limit The term tpermissibie health care related taxes" means those health care related taxes which are broad-based taxes uniformly applied to a class of heatth care items, services or providers, and which do not hold the provider harmless for the costs of the tax, or a tax program for which the Secretary has granted waiver. ‘The term ‘impermissible heath care rotated taxes" means a heatth care related tax that does not meet the requirements of a permissible tax. Federal matching funds for Medicaid expencitures will be reduced by the sum of any revenues received by the state (oF unit of local government) during the fiscal year from impermissible provider-related donations ‘and health care related taxes as described below. + Federal matching funds are not available for provider-related donations except for ‘bona fide provider-retated donations and {or donations for outstationed eligibility workers, + Provider-related donations are any donations or other voluntary payments (in cash or in kind) made directly or indirectly to a state or unit of local government by a health care provider, an entity related to a health care provider, or an entity providing ‘goods or services under the state pian and paid as administrative expenses. + Bona fide provider-related donations are donations that the Secretary of Heaith and Human Services determines have no ‘irect or indirect relationship to payments made under this tie. Regulations may be issued that more clearly define bona fide provider-related donations, + Donations for outstationed eligibility ‘workers are funds expended by a hospital, linic, or similar entity for the direct cost (incliding costs of training and outreach Materia) of state or local agency personnel who are stationed at the entity to determine Medicaid eligibility and to provide outreach services. Beginning in 29 FY ‘83, these donations are limited to ten percent of a state’s total administrative ‘expenditures for Medicaid, This rule applies to revenues received by a state on of after January 1, 1992 (except for certain donations and taxes permitted under a transition period, which are subject to a lim), Revenues received by states prior to this date are not subject to these statutory provisions, even for expenditures funded by these revenues that are not made until after January 4, 1992, PERMISSIBLE CLASSES OF HEALTH CARE PROVIDERS AND SERVICES. ‘The law identifies eight permissible classes of health care providers or services to which provider specific taxes can be applied and be eligible for FFP. The eight classes are: inpatient hospital services ‘outpatient hospital services nursing facility services IOF/MR services physician services home health services ‘outpatient prescription drugs Heaith Maintenance Organization or other Prepaid services Other classes of health care items or services may be estabiished by the Secretary in regulations. ‘SPECIAL RULES FOR TRANSITION PERIOD Under certain circumstances, the new law Permits states to use, without a reduction i FFP, revenues from provider donations and impermissible tax programs in effect before enactment of the new law, for a limited period of time, which is referred to as a “Transition Period." However, the law requires that, in ‘order to be continued without @ reduction in FFP, the tax and donations programs must ‘meet specific requirements. ‘Transtion Period: For most states, the Transtion Period extends until October + 1992. For other states, the Transition Period extends until January 1, 1993, or July 1, 1996. ‘The oriteria for determining the Transition Period are as follows:October 1, 1992 — For states whose state fiscal years begin January 1 through July 1, and which are not eligible for the July 1, 1983 date. January 1, 1993 — For states whose fiscal years begin after July 1, and before January 1, {and which are not eligible for the July 1, 1993, date. July 1, 1993 — For states which are not ‘scheduled to have a reguiar legislative session in calendar years 1992; OR states which are not scheduled to have a regular legislative session in calendar year 1993; OR states which enacted a provider-specific tax program ‘on November 4, 1991, Based on information supplied to HCFA by the National Counci of State Legistatures, the Transition Period will expire on October 4, 41992, except for the following states: Period Expires January 1, 1993: Alabama and Michigan Period Expires July 1, 1999: Arkansas, Kentucky, Nevada, North Dakota, Montana, Oregon, Texas, and West Virginia USE OF DONATIONS DURING THE TRANSITION PERIOD Alter January 1, 1992, states may receive, ‘without a reduction in FFP, revenues received from permissible donations (.2., bona fide donations or donations from outstationed eligibilty workers). in addition, states may recelve, without a reduction if FFP, revenues from existing provider donations programs — even though they do not meet the requirements of being "bona fide" donations programs or are not for outstationed eligibility ‘workers — only during the state's transition period, and subject to the following rules: +The donation program must have been in effect or described in state pian ‘amendments or elated documents submitted to HCFA by September 30, 1991, and +The program must be applicable to the state fiscal year 1992, a8 demonstrated by state plan amendments, written agreements, state budget documentation, ‘of other documentary evidence in ‘existence on September 30, 1991 ; 30 In implementing this provision, states must demonstrate through written documentary ‘evidence submitted to HCFA that the above criteria are met. UMIT ON AMOUNT OF DONATIONS AND ‘TAXES DURING THE TRANSITION PERIOD ‘The amount of revenues states may use from provider donations and health care related taxes is subject to limitation, The limit for a state fiscal year is expressed as a percentage Of the total non-Federal share of Medicaid Program expenditures in that fiscal year (including the state's Medicaid Program administrative costs), less the amount of provider-related donations (other than bona fide donations or donations for outstationed aligibilty workers), and impermissible taxes. The specific percentage to be applied for a state in any fiscal year is the greater of: +25 percent; or + the state's "Base Percentage" which is calculated by dividing the amount of all provider donations and health care related taxes (whether or not they are permissible) ‘estimated to be received in state fiscal year 1992, by the total non-Federal share of Medicaid Program expenditures (including administrative costs) in that fiscal year. LIMIT ON AMOUNT OF TAXES PRIOR TO ‘OCTOBER 1, 1995 Beginning on the day after the state's transition period has ended, and extending until October 4, 1995, revenues received from permissible taxes in excess of the 25 percent cap (or, higher, the state base percentage) will be deducied. After October 1, 1995, there are no limitations on the amount of permissible taxes states may receWve.GLOSSARY OF MEDICAL, MEDICAID, ‘AND INSURANCE TERMS. ‘Actual acquisition cost: The pharmacist’s net payment made to purchase a drug product, after taking into account such items as purchasing allowances, discounts, rebates and the like, ‘Acute Care: Medical care for health problems oF illnesses that are short-term or intense in ature, ‘Aged: For purposes of Medicare enrollment, persons 65 years of age or over are considered to be aged. Medicaid eligibility is determined on the basis of financial need for people who meet Supplemental Security Income eligibility criteria (aged, blind, o disable individuals) and Aid to Families with Dependent Children erteria (adutts and children). Eligibilty determinations are made for an entire economic unit or "case" (some- times a family) based on whether or not one member of a case meets the criteria. For example, an ‘aged case could consist of a 66 year old male and his 63 year old wife. In contrast, a disabled enrollee could be over 65 years of age. ‘Agency for Health Care Policy and Research (AHCPR): ‘The agency of the Public Health Service responsible for enhancing the quaity, approprieteness and effectiveness of heath care services, ‘All Payor System: A reimbursement set up ‘where all insurers reimburse providers using the same accounting system. ‘Akernative Delivery System: A phrase that describes non-traditional health insurance programs that finance and provide health care to members. These inciude health ‘maintenance organizations (HMOs) and referred provider organizations (PPOs). ‘Ambulatory Care: Health care services Provided on an outpatient basis. No overnight Stay in a hospital is required. ‘The services of ambulatory care centers, hospital outpatient. departments, physicians’ offices and home heath care services fall under this heading, ‘Ambulatory Surgery: Any minor surgical Procedures that can be performed at any type of medical facility on an outpatient basis — not Fequiring an overnight stay. 31 Ancillary Services: These services include X- rays, lab tests and other patient services ‘excluded from a hospital's dally room charges. ‘Assignee: The person to whom the rights to a health insurance policy are assigned, either in part or in whole, by the original policyholder. Assignment: An enrolle in the supplementary medical insurance program may agree with a provider of service to assign benefit rights to the provider. When this assignment method is Used, the provider agrees to accept as the total charge for the covered service the ‘amount that is approved by the carrier as the reasonabie charge. The provider submits a Claim to the carrier and is reimbursed for the reasonable charge, minus 20-percent ‘coinsurance and any unmet deductible. The provider may then charge the enrolle only for the coinsurance and unmet deductible, ‘Average Manufacturer Price (AMP): Tho average price paid by wholesalers for products distributed to the retail class of trade. ‘Average Wholesale Price (AWP): The composite wholesale prices charged on a ‘specific commodity that is assigned by the drug manufacturer and is listed in either the Red or Blue Books. Beneficiary: individual who is either using or eligible to use insurance benefits, including health insurance benefits, under an insurance contract. Best Price: Lowest price paid by any purchaser (exclusive of depot prices and single-sward contract prices defined by any federal agency) and includes products with special packaging, labeling, or identifiers, Broker: The go-between for individuals or ‘companies and health insurers, help locate, Negotiate and land health insurance contracts. May also be an agent for the insurance company, delivering policies and collecting premiums. Cafeteria Plans: Employers may choose to offer their employees a wide range of employee benefits, as in a cafeteria including primary health care, dental coverage, life insurance and prepaid legal services among others. Section 125 of the Internal Revenue Service Code allows the employer to set up the plan in a manner so that contributionsmade by employees may be considered as pretax dollars, thus not subject to individual income taxes. Such plans must be maintained {or the benefit of the employees only. Capitation (fee): A reimbursement system where the providers of heath care (physicians, hospitals, pharmacists, etc.) receive a fixed payment for every patient served, regardless of how many or few services the patient uses, For example, an insurer negotiates to pay a physician $1,000 a month to care for ts Subscribers. Regardless of whether the substribers use more or jess than $1,000 in benefits, the physician receives only the $1,000. Health maintenance organizations ‘typically use this system. In essence, 2 provider agrees to provide specified services to HMO members for this fored, predetermined payment for a specified length of time (usually a year), regardiess of how many times the member uses the service. The rate can be xed for all members or it can be adjusted for the age and sex of the member, based on actuarial projections of medical utilzation, ‘Categorically Needy: Under Medicaid, cate- gorically needy cases are aged, blind, or disabled individuals or families and children who meet financial eligiblty requirements for ‘Aid to Families with Dependent Children, ‘Supplemental Security Income, or an optional state supplement. ‘Charity Gare Pools: The assets of several funds combined to cover health care costs to the poor and uninsured. The pools are ‘established by organizations like hospitals and insurance companies to offset a portion of the cost for providing health care to the indigent. Claim: The formal demand by the insured to collect reimbursement for a loss covered under ‘an insurance policy, Closed-Panel HMO: Employment system in which physicians staffing an HMO are employed solely by the HMO. Coinsurance: A cost-sharing requirement under a health insurance policy which provides that the insured will assume a portion or percentage of the costs of covered services. ‘After the deductible is paid, this provision forces the subscriber to pay for a certain percentage of any remaining medical bills — usually 20 peroent. 32 Community Rating: A method heatth insurers use to determine the premium costs for a {group it is planning to insure. Under this system, the insurer bases the premiums on the average health care costs of the community, not the age, sex, occupation or health of individual subscribers. Compettive Medical Pian (CMP): An organization defined by federal Medicare program that provides enrolled memiers with physician, hospital and laboratory services on a capitation basis, These services are pro- vided primary by physicians who are under contract, employed by, or partners in the CMP. ‘A CMP has fewer restrictions imposed than federally qualified heath maintenance organ- ization, but may be a state-licensed HMO. ‘Comprehensive Major Medical Coverage: A form of health insurance that combines the ‘coverage of basic medical expense contracts and specialized medical care contracts into fone comprehensive plan. These plans have both a deductible and coinsurance, Contract: An agreement by which the insurer agrees to provide insurance benefits, to protect, ‘against losses and to provide a writen state- ‘ment outtining the insurance provisions. The insured agrees to pay the insurer a set fee, called a premium, and other considerations. Contributory: A general term that describes, ‘any employee insurance plan where the ‘employee pays part of the premium, ‘Continuous Quality Improvement (Ca): A quality model that incorporates statistical tools to analyze processes and improvement in quality of care Copaymert: Copayments are a type of ‘cost-sharing under Medicaid whereby insured or covered persons pay a specified flat amount per unit of service or unit of time, and the Insurer pays the rest of the cost, Cost-per-Case Limits: Reimbursement limits imposed by the government on each Medicare admission to hospitals, Cost Shifting: A practice by health insurers to increase premiums for one group of business to offset cost from another line of business, like Medicare and Medicaid recipients. ‘Coverage: Entire range of protection provided under an insurance contract.Covered Expenses: Medical and related costs, experienced by those covered under the policy, that quality for reimbursement under terms of the insurance contract. Covered Services: The specific services and supplies for which Medicaid will provide reimbursement. Covered services under Medicaid consist of a combination of manda- tory and optional services within each state. Customary, Prevailing, and Reasonable Charges: Method of reimbursement used under Medicare, which limits payment to the lowest of the following: physician's actual charge, physician's median charge in a recent prior period (customary), or the 75th percentile of charges in the same time period (prevailing). Customary Charge: The charge a physician or supplier usually bill his patients for furnishing particular service or supply is called the customary charge. Deductible: The out-of-pocket expenses that must be footed by an insurance subscriber before the insurer will begin reimbursing the subsotiber for additional expenses. Depot Price: Means the price(s) available to ‘any depot of the federal government, for purchase of drugs from the Manufacturer through the depot system of procurement. Center: Free-standing or hospital- based facility that specializes in diagnosing iiness and injuries. Disability: Condition or conditions that prevent or limit an individual's ablity to engage in normal activities, These may be temporary. Disability Income insurance: Type cf health insurance that periocically pays a disabled subseriber to replace income lost during the period of cisabilty, Dismemberment: Loss of function of body pants stemming from accidental physical injury. DRG: Diagnostic Related Group, a system where the hospital receives a fixed payment for ‘each type of medical procedure, regardless of whether the hospital's cost is greater or less than the payment itseit, The categories are defined by medical diagnosis, treatments, patient age, patient sex and discharge status. ‘The federal goverment uses this system to reimburse hospitals for care delivered to Medicare subscribers. 3 Drug Utiization: The prescribing, dispensing, administering and ingestion or use of pharmaceutical products, Drag Utiization Review: Used by Medicaid and other heaith plans to monitor the frequency and usage of prescriptions. ‘Typically, a DUR committee examines the ‘number of prescriptions per member per month and the average cost per prescription. ‘The utiization and costs of pharmaceuticals are reviewed by the committee for each physk- cian, physician group, medical speciaity, retail pharmacy, employee group, and member. Early and Periodic Diagnosis, and Treatment (EPSDT): The EPSOT program covers screening and diagnostic services to determine physical or mental defects in recipi- ‘ents under age 21, as well as health care and ‘other measures to correct or ameliorate any defects and chronic conditions discovered Employee Benefits Program: Health insurance ‘and other benefits, beyond salaries, offered to ‘employees at their place of work. The ‘employer typically picks up all or part of the ‘cost of the benefits. Estimated Acquisition Cost (EAC): Estimated acquisition cost based on price information supplied at regular intervais by the DHHS. ‘This information will show estimated costs to groups of providers classified by dollar volume of drug sales. Exclusion: Clauses in an insurance contract ‘that deny coverage for select individuals, ‘f0ups, locations, properties or risks. Exclushity Clause: A part of a contract which prohibits paysicians from contracting with more: than one health maintenance organization or Preferred provider organization, Expenditures: Under Medicaid, “expendturest refers to an amount paid out by a state agency for the covered medical expenses of eligible anticipants, Experience Rating: A system where an insurance company evaluates the risk of an individual or group by looking at the applicant's heaith history. Extended Care: Long-term care, ranging from routine assistance for daily activities to sophisticated medical and nursing care for those needing it. The care, covered undercertain insurance policies, can be provided in homes, day-care centers cr other facilities. Family Planning Services: Family planning services are any medically approved means, including diagnosis, treatment, drugs, supplies land devices, and related counseling which are furnished or prescribed by or under the supervision of a physician for individuals of childbearing age for purposes of enabling such individuals freely to determine the number or spacing oftheir children. Federally Qualified HMOs: HMOs that meet certain federally stipulated provisions aimed at protecting consumers: e.g. providing a broad range of basic health services, assuring financial solvency, and monitoring the quality of care, HMOs must apply to the federal government for qualification. The process is administered by the Office of Prepaid Health Care of the Health Care Financing Administration (HCFA), Department of Health and Human Services (DHHS). Fee for Service: The traditional way of billing for health care services. Under this system, there is a separate charge for each patient vist and the service provided. First-Dollar Coverage: Health policies that pay all medical expenses up to a predetermined limit, without a deductible charge. Fiscal Agent: A fiscal agent is a contractor ‘that processes or pays vendor claims on behaif of the Medicaid agency. Fiscal intermediary: The agent (Blue Cross ot an insurance company, for example) that has contracted with providers of service to process claims for reimbursement under health care ‘coverage. In addition to handling financial ‘matters, it may perform other functions such as providing consuttative services or serving as a enter for communicating with providers and making aucits of providers’ records. Fiscal Year: Any 12 month period for which ‘annual accounts are kept. The Federal Government's fiscal year extends from Oct, 4 to the folowing Sept, 30. Fixed Fee: An established “fee schedule for pharmacy services allowed by certain st and private third-party programs in Tieu of cost-of-doing business markups, 34 Formulary: A list of selected pharmaceuticals ‘and their appropriate dosages fet to be the most useful and cost effective for patient care. Organizations often develop a formulary under the aegis of a pharmacy and therapeutics (P27) committee. In HMOs, physicians are often required to prescribe from the formulary Free-Standing Hospital: Any hospital that isn't affiated with @ multinospital system. Gatekeeper: A component of an independent practice association HMO that requires a subsoriber to see a primary physician and get the physician's approval before seeing a specialist about a medical condition. Generic Substitution: Substituting a generic version of a branded off-patent pharmaceutical for the branded product when the latter is prescribed. Some HMOs and Medicaid programs mandate generic substitution. Mandatory generic substitution within the Medicare program is currently being debated in Congress. Group Practice Association HMO: Type of health maintenance organization made up of three or mote physicians that formally afign to provide health care to a group over a pre- negotiated time period for fixed, prepaid rates. Health Care Financing Administration (HCFA): ‘The agency of the Department of Health and Human Services having the delegated authority 10 operate the Mecicaid Program. Health Maintenance Organizations (HMO's): Health maintenance organizations provide a full range of health benefts to a specified Group of subscribers for a fixed prepaid fee, regardless of the expense of the care needed. The fee can either be paid by the subscriber or an employer. IMO - Mode! Types: Group Practice or Closed Panel - The HMO contracts with @ group of prysicians, which is paid a set amount per patient to provide a specified range of services. The group of physicians determines the compensation of each individual physician, often sharing profits, The practice may be located in a hospital setting or clinic. Like staff mode! HMOs, the medical facility usually contains ‘a pharmacy, but in some cases the HMO contracts for pharmacy services.‘Staff Model HMO - Type of health maintenance organization where subscribers typically are treated at one central facility or a small group of facilties run by the HMO. Medical care is given by physicians who are employed on a fulltime basis by the HMO's management to treat subscribers, The HMO facility often contains a pharmacy, but in some cases the HMO will contract for pharmacy services. As in all the models, the affliated pharmacy may be paid ether a fee-for- ‘service or a capitation. Network — A Network Model HMO is essentially an IPA of group practices rather ‘than individual physicians. Each of the ‘contracted group practices sees HMO patients as well as fee-for-service patients in its group offices. Home Health Services: Services and items fur- nished to an individual who is under the care of a physician by a home heath agenoy, or by others under arrangements made by such agency. Services are furnished under a plan established and periodically reviewed by a physician. They are provided on a visiting basis in an individual's home and inciude: nursing, physical therapy, dietary, counseling, and social services; part-time or intermittent sskiled nursing care; physical, occupational, or ‘speech therapy; medical social services, medical supplies and appliances (other than publish tne proposes MAC mis inthe Federal Ragster:ullze a comment period and etter considering alo the ‘comments, publish the final ntie in the Federal Register. However, the procsts would be shortaned by not ‘conducting a public hearing before the PRB and eliminating the requirement for specific PRE consultation with FDA {or each drug ‘We proposed three new requirements that we would caneider bale ‘establishing a MAC lini. The fist Fequiroment would be that a of tho formulations of the drug approved by ‘the FDA have been evaluated a5 therapeutically equivalot. The second requicoment would be that atleast roe suppliers advertise the drug (which ha. been classified by the FDA ae category "at in the FDA's therapestic ‘cuivalence evaluations publication) in the Red Beck or Blue Book. Finaly, we speced thet we would expect reduce total State and Federal Medicaid expenditures by st least '850,000 annually for any ofug fr which ‘2 NAC limit isto be established, We specitiod inthe proposed raguletions that we would survey drug wholesalers for assurances that hey: (1) Are carrying the multiple source products at er below the proposed. MAC limits; or (2) would cary the products inthe event that mits are ‘tablened, Wa also stated tha, Iritaly, we would eondiet surveys to $35.80 (@) Texas: Amount paid pharmacy equals (EAC + $4.55) divided by 0.970 (©) New Hampshire: $1.00 - branded or compound products; $.50 - generics (©) Michigan: AAC with AWP minus 10% screens (7) New Jersey: AWP minus up to 6% based on Medicaid percentage of Rx sales (®) Colorado: $2.00 trade name; §.50 generic (MAC) products ®) Michigan: $3.89 effective 10/1/93 (10) Oklahoma: $1.00 for prescriptions up to $29.99; $2.00 for prescriptions costing more than $30.00 (11) Vermont: $1.00 copayment; $2.00 copayment when ingredient costs exceed $29.09 (12) Utah: $3.90 urban; $4.40 rural NOTE: The dispensing fees, copayments and ingredient reimbursement are current to July 1992, ‘The average Fx price, and prescriptions processed data are approximations based upon 1991 fiscal year data, 105NPC - 1993. AVERAGE EXPENDITURE PER RECIPIENT FOR PRESCRIBED DRUGS YEAR 1987 1988 1989 4990 1981 1992 US Average $203.00 $215.00 $222.00 $256.00 $276.00 $307.00 State ‘Alabama 15200 218.00 222.00 © 289.00 26000 329,00 Alaska 206.00 216.00 257.00 262.00 329.00 ‘Arkansas 249.00 231.00 236.00 282.00 306.00 302.00 Caliornia 15000 463.00» 186.00 201.00 222.00 247.00 Colorado 208.00 241.00 234.00 264.00 276.00 283.00 Connecticut 185.00 267.00 288.00 288.00 377.00 384.00 Delaware 166.00 © 178.00 © 197.00 © 207.00 257.00 281.00 De" 173.00 206.00 161.00. 255.00 29000-32400 Florida 248.00 © 261.00 -311.00° 312.00 330.00 827.00 Georgia 277.00 291.00 © 287.00 287.00 274.00 275.00 Hawaii 18100 171.00 © 180.00 © 2aa.00 «280.00 316.00 idaho 104.00 243.00 270.00 © 801.00 313.00 318.00 tinois 17000 178.00 199.00 © 21800-22600 227.00 Indiana 316.00 363.00 402.00 425.00 438.00 486,00 owa 194.00 223.00» -254.00 © 286.00 318.00 362.00 218.00 204.00 213.00 225.00 250.00 297.00 42400 4480017400 = 19100-27300 ©——383.00 243.00 © 265.00 192.00 284.00 824.00 371.00 230.00 © 252.00 283.00 301.00 82400 362.00 201.00 © 21200 249.00 286.00 305.00 345.00 228.00 260.00 282.00 284.00 «390.00 389.00 177.00 191.00 209.00 226.00 254.00 274.00 20300 © 286.00 24800 © 276.00 307.00 331.00 173.00 166.00 185,00 218.00 243.00 280.00 17200 194.00 205.00 211.00 259.00 372.00 203.00 168.00 225.00 266.00 316.00 384,00 23200 253.00 267.00 287.00 323.00 386.00 21800 © 217.00 © 283.00» 268.00 = 276.00 289.00 286.00 $24.00 $48.00 © 340.00 831.00 367,00 203.00 241.00 © 279.00 © 324.00 «367.00 405.00 207.00 © 233.00 229.00 225.00 226.00 240,00 24g.00 258,00 262.00 319.00 306.00 316,00 North Carolina 242.00 250.00 258.00 27600 «271100 287.00 North Dakota 27200 © 266.00 © 274.00 = 301.00 321.00 881.00 Ohio: 19300 201.00 26.00 260.00 291.00 319.00 Oklahoma 201.00 215.00 225.00 242.00 © 269.00 289,00 ‘Oregon 90.00 2283.00 233.00 © 249.00 272.00 © 305.00 Pennsylvania 207.00 231.00 © 262.00 307.00 341.00 384.00 Rhode Island 79900 249.00 235.00 245.00 258.00 276.00 South Carolina 47300 180.00 20200-22800 © 824.00 248,00 South Dakota 22900 © 249.00 262.00 289.00 284.00 342.00 Tennessee 244,00 260.00 © 263.00 248.00 271.00 818.00 Texas 461.00 468.00» 175.00 180.00 187.00 215,00 Utah 17700 185.00 199.00 223,00 245.00 284.00 Vermont 21300 242.00 = 270.00 © 28200 -817.00 342.00 Virginia 239.00 267.00 277.00 «30000» 821.00 350.00 Washington 187.00 480.00 20100-23200 © 263.00 290.00 West Virginia 430.00 148000 154.00 146.00 201.00» 274.00 Wisconsin 23500 278.00 © $2200 «358.00 © 400.00 442,00 Wyoming 225,00 © 24200 211.00 Source: HCFA 2082 reponts, compiled by state Medicaid program officials, Although the reports have 211.00 been reviewed and edited by HCFA, they do not guarantee the accuracy of the data. (See HCFA Caveats) Despite these caveats, the 2082 data represents the most accurate figures available on the utilization of state Medicaid services. Arizona omitted because of the AHCCCS capitation program. + Juedstions reporting some or all nursing home prescription expendture in pe elem musing hom 106NPC - 1993 PERCENTAGE OF MEDICAID EXPENDITURES ALLOCATED TO PRESCRIPTION MEDICATION STATE 1968 1989 1990 1991 1992 US Total 67% 67% 62% 7.0% 74% Alabama 108 103 29 ea 10.9 Alaska 39 34 40 47 58 ‘Arizona 59 03 Arkansas 94 30 a6 87 83 California 78 83 as 88 94 Colorado 60 65 68 64 65 ‘onnecticut 48 44 43 46 SA Dotaware 45 49 43 52 55 De 3s 45 58 38 4g Florida a4 94 24 24 104 Georgia 108 104 69 89 9 Hawaii 72 78 a4 84 at Idaho 65 70 73 74 72 inois 78 77 78 74 68 Indiana as Ba as 85 87 lowa a1 83 85 84 80 Kansas 68 68 61 66 17 Kentucky 83 87 87 82 10.4 Louisiana 108 72 a9 92 Maine 70 72 7A 74 Maryland 55 60 62 60 Massachusetts 80 48 43 54 Michigan ed 80 73 82 Minnesota 47 48 52 54 Mississippi 114 119 122 114 Missourh 79 79 74 88 Montana 62 63 68 74 Nebraska 87 85 a3 3s Nevada 53 58 56 60 New Hampshire 4.9. 53 a7 50 New Jersey et 64 68 68 New Mexico 83 80 78 76 New York 42 39 43 38 North Carolina 73 74 73 70 North Dakota 43 43 51 49 ‘Ohio. 64 66 66 7A Oklahoma 58 60 66 TA Oregon 80 78 7A 72 Pennsylvania 68 77 a2 85 Rhode island 48 48 48 40 South Carolina 72 70 68 69 South Dakota 52 52 54 83 Tennessee 108 144 gs 97 Texas TA 72 7A 7A Utah 59 64 68 69 Vermont a4 85 ag a7 Virginia as 86 84 as Washington 61 65 as 30 West Virginia 78 84 73 T3 Wisconsin a0 78 82 82 ‘Wyoming 84 74 107NPC - 1993 RANKING OF STATES BY DISPENSING FEE, 1993 Under $3.00 Colorado 4.08 Montana 2.00-4.08, a a Missouri 4.09 babel on Connectiout 410 ieee Veit Minnesota, 440 Florida 423 ‘Uncler $4.00 Vermont 425 North Dakota 425 Nebraska 2.84-6.05 : Idaho 430 Ohio 923 : Virginia 440 New Hampshire 8253.65 ; Georgia 4at Maine 335 Nevada 442 Rhode Island 340 ce aa 345-11. ee 7 aoe . Arkansas 4.814.108 EAC erste = Hawai 487 oo oe Wisconsin 4.69 — o moreg eee eae South Dakota 475 peal Pi Kentucky 478 igen : Texas (EAC + $4.85) + by 0.970 New Jersey 373-4.07 Mississippi 491 Kereae: beeeetl Maryland, 499/617 Utah 3,90-4.40 Tennessee ast — ner $500 Oviahoma a0 Louisiana 5.30 ei oo Alabama 5.40 lien North Carolina 5.60 Jowa 4.02625 California 4.05 South Carolina 4.05 Massachusetts 4.06, ‘Arizona — all plans captated under AHCCCS, Note: When reviewing total pharmacy reimbursement, both the dispensing fee and the ingredient reimbursernent basis or EAC must be considered. 108NPC - 1993 MEDICAID LIMITS ON PRESCRIPTION DRUGS, BY JURISDICTION: JULY 1993 State ‘Alabama ‘Arizona’ ‘Arkansas California Colorado Connecticut Delaware be Florida Georgia Hawail Idaho Minois Indiana lowa Kansas Kentucky Louisiana Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon PennsyWvania Rhode Isiand South Carolina ‘South Dakota Tennessee Texas tan Vermont Virginia Washington West Virginia Wisconsin Wyoming Copayment ‘Amount 503.00 50-3.00 1.00 2.00/.50 50 1.00 * axes aptton Pan Rx Limit Per Month No No Yes @ No No No No No, res © Yes" No No No No No No No No No No No No No, Yes ® No No No, Yes ® No No No, Yes ® Yes ® No No, Yes ® No No No, Yes ® No, Yes® Yes ® No No No No No No, Yes 109 Refi Limit Yes No Yes No, Yes" No No. Yes ® Yes ®” No No No, Yes No No No, Yes ¢® Yes Yes Yes ® Yes © No No, Yeo No No, Yes (9 No, Yes * Yes“ No, Yes Yes Yes" Yes Yes No, Yes” Yes No, Yes © No. Yes Yes Yes Yes © Quantity Limits on Limit Yes Yes "2 Yes Yes 3 Yes 02 Ye oa No, Yes "* No, Yes 2 Yes 2 Yes 2 Yes 0 No No, Yes °? ca Yes © < a 0002000800008100000008790B0000000000B00B000B00m0 OO] ‘See next page for key definitionsNPG - 1993 MEDICAID LIMITS ON PRESCRIPTION DRUGS, BY JURISDICTION: JULY 1993 KEY o 5 refil tit @ 2 cof fit @ 3 Pxs per month ® 4 Ras per month 6 5 Ras per month © 6 Pixs per month @ Some, but not ail Res ® Stefi imi (@ 7 Rxs per month (10) 5 Fxs per month/aduh; 6 Rxs per month/child (11) Upto one year (12) 90:34 days supply or 100 units (13) 100 days supply (14) No moro than 60 days or less than 30-day supply, (18) 180 days supply (16) No more than 249 tablets or capsules per prescription (17) No more than the greater of 60 days or 100 units (18) After intial fing, one dispensing fee per 30-day period for designated maintenance drugs (19) S month supply maximum (20) 14 refit tit (21) 1 refill per steep aids, antianxiety products, H, antagonists (22) 30-day supply for nursing home residents, minimum (23) Applies to aspirin/acetaminophen/prenatal vitamins (24) 30-day supply minimum (25) 2 refill imit/refils up to one year for maintenance drugs (26) 1 refill per month per prescription with some exceptions OTC Status A—All OTC's Reimbursed 1B — Most OTC’s Reimbursed (© —Few OTC’s Reimbursed D— Insulin only — Most, for nursing home patients only F — Prior Approval 110NPC - 1993, MISCELLANEOUS MEDICAID PROGRAM CHARACTERISTICS, 1992 Fas by —_Giaims Coverage of Unit Dose Mandatory Vaccines i, 7 e State NP or PA’ Filing %? j* Substitution? Rei Alabama No 3/97/0 ABC Yes No Yes Alaska Yes -40/60/0 ‘ABC Yes Yes Yes ‘Arizona Yes NA NA NA NA NA ‘Arkansas No 26/82 ABC Yes No Yes California Yes (NP) 16/84/0 ABC No Yes Yes Colorado Yes 45/55/0 ABC Yes No Yes Connecticut Yes 24/7610 ABC No No Yes Delaware No 36/64/0 ABC Yes No = DC Yes +10/90/0 ABC Yes No Yes Florida Yes 32/60/0 ABS Yes Yes Yes Georgia No 25/75/0 ABC No No Yes Hawaii No 2080/0 ABC No Yes Yes Idaho Yes 31/69/0 ABC Yes No Yes Winois No 0/2010 ABS No Yes Yes Indiana No 30/7010 ABC Yes Yes towa Yes (PA) 20/80/0 ABC Yes Yes Yes Kansas Yes NA AB No No _ Kentucky No 30/70/0 ABC Yes No Yes Louisiana No 4/96/0 ABS ‘Yes No Yes Maine Yes 40/60/0 ABC No Yes Yes Maryland Yes (NP) 1/25/74 ABC Yes No Yes Massachusetts Yes (PA) 10/90/0 ABC Yes Yes i Michigan Yes (PA) _5/95/0 ABC Yes No Yes Minnesota ‘Yes 20/8010 ABC Yes Yes Yes Mississippi Yes (NP) 30/70/0 ABC Yes No No Missouri Yes (PA) 14/19/67 ABC Yes No No Montana Yes 38/62/0 ABC Yes Yes Yes Nebraska Yes 0/60/0 ABC No No Yes Nevada Yes 65/35/0 ABC Yes No Yes New Hampshire Yes 12/88/0 ABC Yes No No New Jersey Yes (NP) _5/95/0 ABC Yes Yes Yes New Mexico Yes 3070/0 ABC No Yes Yes New York Yes 8/95/0 ABC No Yes Yes Norn Garoina -Yes._——+19/87/10 ABC No Yes Yes North Dakota’ Yes 10/8010 ABC No No Yes Ohio No 15/85/0 ABC No No Yes Oklahoma Yes (PA) 16/84/0 ABC Yes No Yes Oregon Yes 18/84/0 AC Yes Yes 7 Pennsywania Yes (PA) 12/87/1 ABC No No Yes Rhode Island, Yes 45/85/0 BC No Yes hi South Carolina Yes (PA) SO/50/0 ABC Yes No Yes ‘South Dakota ‘Yes 30/70/0 ABC Yes No Yes ‘Tennessee Yes (NP) 1/13/86 ABC Yes ‘Yes Yes Texas Yes 8770/25 8c No No Yes Utah Yes '50/80/0 ABC No No Yes Vermont Yes 15/85/0 ABC Yes Yes Yes Virginia Yes 45/55/0 ABC Yes No Yes Washington Yes 6194/0 ABC Yes Yes Yes West Virginia Yes (PA) 5/5/90 ABC No Yes Yes Wisconsin, Yes 23/7710 ABC Yes No Yes wyoming Yes 54/46/0 ABC Yes Yes Yes See question key, next page utNPC - 1998 MISCELLANEOUS MEDICAID PROGRAM CHARACTERISTICS, 1992 (QUESTION KEY 4. oes your program allow for nurse practitioner or physician assistant prescribing? 2 What percentage of your Fix claims are submitted by individual paper claims vs. electronic batch claims, or on-line, POS claims? 3. Does your state reimburse for injectible medicine (including IV coverage) used in (A) physicians’ offices, (B) home health care, (C) extended care faciity? 4, Does your state reimburse for unit dose packaging? 5 Does your state Medicaid program require the pharmacist to dispense a generic mouftisource product when available? 6 Are vaccines reimbursable by Medicaid as part of the EPSDT service? 12NPC — 1993 DRUG UTILIZATION REVIEW Pro. —-Retro- State Contact Telephone spective spective Contractor Alabama Joe Hicks 205/277-2710 1883 1993 AL Rx Assn/Aubumn Univ, Alaska Dave Campana 907/561-2171 1983 © 1983—_—*Frst Health Services Corp. Arizona Philip Hellyer 602/234-3855 ‘Arkansas Buddy Bowen 501/372-5250 1984 1886_—_AR Pharmaceutical Assoc. California Michael Neft 916/654-0532 1993 No Colorado Kim Gordon 309/8663176 1994 Univ. of Colorado Connecticut Elizabeth Geary 203/566-2421 No 1991._-—_—Health Information Design Delaware Carmen Herrera 802/577-4000 19931983 oc Donna Bovell 202/727-0753 1883 Yes Florida ‘Susan McLeod 904/487-4441 1994 1982_——_—#FL Pharmaceutical Assoc. Georgia Etta Hawkins 404-656-4044 19931992 Hawait Fon Taniguchi 0g/5865419 1993 1993 Idaho Wiliam Whiteman 208/334-5795 1992 1983 —Idaho State University Wincis Starlin Greatting 2i7rezss6s = 19931998 Indiana Marc Shirley 317/202-4943 19931993 lowa Michael Pursel 818/270-0713 No 1984_—_—TA Foundation Medical Care Kansas Renee Readinger ——912/232.0489 «1993 Yes KS Pharmacy Foundation Kentucky Gene Thomas 502/564-4321 No —1988._—_*First Health Services Corp, Louisiana Dan Scholl soaje2a/7051 1993-1991 -Paramax Maine Robert Carrot 207/287-2674 19871987 Maryland Richard Seaborg «410/225-1743 «1993-1987 _—First HealttyMid Atlantic Massachusetts Dennis Lyons 617/74266068 Yes. Yes _Heatth Information Design Michigan Mary Sandusky 817/335 No 1985 ‘First Heath Services, Minnesota Ron Rogers 612/297-7791 19931979 Mississippi Mike Kelly 601/981-0416 1993 «1984 MS Pharmaceutical Assoc. Missouri Jayne Zemmer 314/751-6970 1994 ©1984 PharMark/GTE. Montana Mark Eichier 406/442-4020 1993 «1998. PharMark Nebraska ‘Alison Jorgensen 402/420-1500 1993 -«=—««1984 NE Pharmacists Assoc. Nevada Laurie Squansoff 702/687-4869 No —«1993.__—IA Foundation Medical Care New Hampshire Chip Nadeau eoge71-4s19 19831983. EDS/HID New Jersey Ed Vaccaro eos/ss-2724 §=— 19031993 New Mexico Chuck Reynokis SOs/e27-4406 © 19831993 New York Michael Zegareti 518/474-6888 19921978 North Carolina Linda Cross. 919/733-6990 19981983 North Dakota Deb Larkin 701/258-4022 1992 ND Pharmacy Service Corp. Ohio Melanie Irwin 614/466-7096 19981988 (Oklahoma Darendia McCauley 405/557-2539 19931993 Oregon Diane Eiseit 503/378-9002 Yes Yes OSPA/HID Pennsylvania John Walter 717/772-4606 19931983. EDS Rhode Island Paula Avarista 401/464-2183 19931993 Medco South Carolina Caroline Sojourner 809/253-6179 1993 1988-—_—~Frst Heath Services. South Dakota Dave Helgeland 605/688-4240 Yes Yes SD College of Pharmacy Tennessee H. Leo Sullivan 615/741-0213 1993 -1993——_~First HeathvUnwv. of TN Texas ‘Curtis Burch 512/338.6988 © 19931993 Utah Duane Parker 801/538-6495 Yes Yes Vermont Chet Briggs 802/261-2745 1893-1983. EDS/Medco Virginia Carol Pugh 204/786-3820 1993 ©1993 —_—*First Heath Services, Washington Garth Hoimes 206/586-7094 19911991 West Virginia Diane Crouch 304/826-1700 1893 1993 Consutec. Wisconsin Tod Collins 608/263-4847 Yes, Yes Univ of Wisconsin wyoming Debra Devereaux «909/225-1904 1993 1993. —PharMark ‘At printing, several states are stil in the process of developing DUR programs and have not yet implemented them per OBRA ‘90, 113NPC - 1993 PATIENT COUNSELING REQUIREMENTS (May 1993) ust Part ‘Counseling be 1s Pationt Councetng Required? Requires Perormad by Stato Personal, Ae Patent Foral For Madieais Crue) «Facet Face by = rofles sate Patents Patnts Ory Reguaton te Pramacist’_—_—_Mandateg? Alabama ‘Yes Rule Yes * NO Aas Yee us Yee Ne pazona Yes ule Yes No ‘Arkansas Yes Rule ves ves Cattornia Ye Fue Yes ves Colorado Pending Pending Rule © ‘Yes, No Connecticut Yes Statute Yes ¢ Yes Delaware Yes Rule No? Yes: oct Pending Rule Pending Florida Yes: Rule Yes" ‘Yes Georgia Yes Rule Yes © Yes: Hawai No ves ule Yes Yeo ldaho ye stanse ves, ves Minois Yes ‘Statute, Yes & Yes: ingtana yes Ne fle Yes" tes iowa Ye Fle Yes, Yes Kansas Yes Rule Yes * Yes. Kemucky Yes Emergency Ru! Yes * vee, Lovisiana Yes: Rule Yes * Yes" Wine Yes site Yes ‘es Manlana ves Sate No No Massachusetts Yes staeyaule Pending Yes Ne Michigan Pending? ‘Statute Pending No Minnesota Peneing Pending fue Pereing Yee Mississippi Yes Rule Pending Yes * Yes Missouri ‘Yes Rule Yes ® Montana Yes ule Ne Yes Nebraska Pending Y No ‘Statute Pending No Pending Nevada Pending “ ‘Statute Pending Pending Pending New Hampshire Yes Rule Pending Yes‘ ‘Yes New Jersey. Yes Rute Yes. Yes New Mexico: ‘Yes Rule. Yes” Yes ‘New York ‘Yes ‘Regulation Yes" Yes Nth Galina Yes ule Yee Yes Nor Davota Yes sate ves Yes one Yes ule ves, Yes Oklahoma: Yes" Yes" Rul Yes* Yes: Oregon Yes ule es, Yes Pennsylvania Pending“ Rule Pending Yes" Yes: Puerto Rico © No No. Roce ire ver ave No Yes ‘South Carolina Pending? Guidelines ® Rule Pending Pending South Dakota ves svete ‘Yes Yes Tennessee Yes No rule Yes, Yes Texas Yes Rule Yes Yes tan Yes Rule Yes Yes Vermont Yes Rule No, Yes Virginia ‘Yes: ‘Statute Yes * Yes ‘Washington ‘Yes Rule Yes * Yes: ‘West Virginia: Yes* Rule Yes ® ‘Yes Wisconsin "Yes Rule ‘ee Yes wyoming Yes ® Regulation ° ‘Yes: Yes Source: 1992 NABP Survey of Pharmacy Law 14NPC - 1989) PATIENT COUNSELING REQUIREMENTS (May 1993) LEGEND: A Face to face if prescription is delivered to the patient within the pharmacy; otherwise, by telephone: in writing. Required for ali new prescriptions, and as appropriate for refills. ‘Aweak regulation currently exists. Colorado regulation needs legislative authority Whenever practicable, ‘The Board is drafting a new prospective DUR regulation which would reftect OBRA ‘90 language. Information current only as of October, 1992. amooo Face to face if prescription is delivered to the patient within the pharmacy; otherwise, a written offer to counsel with toll-free telephone access to a pharmacist must be made. @__ Unless pharmacist deems counseling inappropriate or unnecessary, in which case it may be written, by telephone, or as considered appropriate, H_ Where applicable. Emergency reguiation effective January 5, 1899; an original reguiation based on the language of the emergency regulation is presently in the subcommittee review process. bill has been introduced into the 1893 Michigan legisiate session, but has not yet been passed \Legisiation is pending; regulations will be crafted upon passage ot legislation. In person, whenever practicable, or by telephone. Rule/regulation is in the process of being revised. Under review pending legislation. Public hearing was scheduled on January 27, 1993. Final regulation to be adopted by the Board at meeting after the hearing and continued through legislative process. Health and Human Services Finance Commission Guidelines. ‘State regulations are in place, which become effective July 1, 1993, However, these regulations are restricted by legislation. Wyoming is currently complying with the provision of federal OBRA ‘90 legisiation, R__ Regulation is being considered by legisiative committee, S Required tor new Medicaid patients. Etfective July 1, 1993, Tf offer to counsel is accepted, patient profile is mandated; however, it patient refuses offer to counsel, patient profile is not required. U___ Patient counseling regulations were introduced in 1993 legislative session as LB4S6. V___ In person, whenever practicable, or by telephone; when the patient or agent is not present when the prescription is dispensed, including but not limited to a prescription that was shipped by mail, the pharmacist shall insure that the patient receives written notice of his or ner right to consuttation and ‘telephone number to obtain oral consuitation from a pharmacist. Required for all new and refill prescriptions. W. Face to face if prescription is delivered to the patient within the pharmacy; otherwise in wring Required for all new prescriptions, and in the professional judgment of the pharmacist for refils. ozzerxe - 2 5NPC - 1993 Introduction to HCFA 2082 Data Tables ‘The data in the attached tables are based on information reported to the Health Care Financing Administration (HCFA) by 60 States, the District of Columbia, Puerto Rico, and the Virgin Islands. The information is based on the federal fiscal year beginning October 1, 1991 and ending September 20, 1992. The data are reported on the Form HCFA-2082, Statistical Report on Medical Care: Eligibies, Recipients, Payments, and Services, However, HCFA cannot guarantee the accuracy of the data, which were obtained from State Medicaid agencies, Aithough HCFA cannot very the accuracy of the data because it does not originate from their office, they do run the data through a reasonably thorough set of edits. The edits consist of the following: Row and column totaling A comparison of row and column totais between corresponding sections + Across check of subtotals between ‘corresponding sections Matching recipients to eligibles and dotars ‘A check for negative values ‘A check for missing or zero (0) entries intemal data inconsistencies such as: ¥ Dollars present in Section x but no Recipients in Section Y Family Planning Services using Aged basis of elgibilty data /- Inpatient Mental Hospital Age Under 21 using Aged basis of eligibilty data Y EPSDT Services using Aged basis of ligibilty data ¥ Aged Mental Health Services using ‘AFDC Children basis of eligibility data Aged Mental Heatth Services using Other Title XIX as basis of eligibility data This is the first year a State Medicaid Statistios Footnote and Amendment Listing has been provided to accompany the HCFA 2082 Tables. This is also the first year HCFA has taken more of a “hands oft attitude towards the data. In the past, HCFA has often wrestled with the problems poised by the singular ‘exception or apparent anomaly within the data reported to them by the States, HCFA views this listing as your opportunity to appraise the 116 contents of a State's footnote as well as the suitabilty of the changes te the submitted data. In the same sense that HCFA cannot police the recording, classification and reporting ot the data by the States, they cannot impose upon them a standardized form of footnote HCFA has preserved the footnote as a free {orm of reporting on the part of the States which has been subjected to a minimum of ‘edits on thelr par. As for the amendments to the data, HCFA-20825 submitted by States frequently contain obvious errors in one or ‘more cells in the report. For cells obviously in terror, HCFA tries to make the necessary corrections, Sometimes, itis necessary to estimate certain values to make them appear more reasonable or to infer corrected totals, though an analysis of row and column subtotals in corresponding categories in separate sections, The listing of the HCFA amendments to the data has been included with the State's footnotes to facilitate a State by State analysis. if possible, HCFA has provided an abbreviated explanation of their reasoning along with the change. HCFA also identify cells which they suspect are in error that they have not changed. You should be aware that there are several classes of apparent anomalies appearing within the Tables. These inciude negative ‘expenditures, deflated values and “unrecorded recipients which are due to the reporting of the recoupment of past payments. It has been pointed out that a negative adjustment, indicating a recoupment of funds previously expended, must be included to provide an accurate accounting of expenses over the long term, HCFA no longer adjusts negative numbers for dollar amounts aithough they stil cannot abide by 2 negative value for recipient or eligibity amounts. Previously, the recoupment of funds figured into larger expenditures by the States were not adjusted as with the negative totals. Theretore, ‘what seemed to be overt irregutarties appeared within the data. For example, a State has been known to repon the expenditure of just two dollars on FamilyNPC - 1993 Planning Services in a single maintenance assistance category for the entire fiscal year. Nonetheless, this State did not spend two dollars for the entire fiscal year. This State ‘spent an amount two dollars over the recoupment of funds for that maintenance assistance category over the fiscal year. The State totals reported in the Tables are a reconciliation of the recoupment of past ‘expenditures and payments. Please be aware that any row or column total can have a Negative value or reflect a defiated value when there is a recoupment of funds for a cell affecting that total ‘The reconciliation of the recoupment for the fiscal year can also account for the appearance of a negative number as a dolar ‘amount with the absence of any recipients reported in the corresponding assistance category. If this causes you concern you may wish to analyze State specific data Questions about these tables or other Medicaid data should be directed to Tony Parker at (410) 597-3792 or FTS-987-9792. He will be happy to supply you with all of the State ‘specific data on diskettes along with a listing of State contacts to faciitate your research efor. 7TABLE 1. MEDICAID RECIPIENTS BY MAINTENANCE ASSISTANCE STATUS AND BY REGION AND STATE: FY1992 (GATEGORICALLY NEEDY TOTAL RECEIVING NOT RECEMVING JON AND ST/ RECIPIENTS H ASH ‘ALL JURISDICTIONS: ‘3,150,004 75,805,043 31,808 BOSTON: REGION | ‘1527.02 ‘970,812 155,783 ‘CONNECTICUT ‘316278 169,201 13945 MAINE 162.440 91871 48,851 2IMASSACHUSETTS 686,235 947,792 36,097 {NEW HAMPSHIRE 71479 “3471 15.631 2IRHODE ISLAND 219)388 174,983 15,508 ‘VERMONT 7/502 43,654 28751 NEW YORK: REGION 1! 4,153,410 2,423,170 208,263 SINEW JERSEY ‘697,083 488,844 103,507 NEW YORK 2587,701 1,898,458 99,514 PUERTO RICO "385,405 23.972 0 VIRGIN ISLANDS 19221 4,896 202. PHILADELPHIA: REGION ti 2767777 1,741,569 997,942 DELAWARE 60,696 8519 DISTRICT OF COLUMBIA 108,514 10,279 MARYLAND 377.075 23.997 PENNSYLVANIA 1,398,994 221,06 VIRGINIA ‘515,064 48,035 WEST VIRGINA 308,034 47,806 ATLANTA: REGION IV 5,539,821 412,981 TALABAMA 466,918 52,502 FLORIDA 1,837,928 118,160 S/GEORGIA ‘863,670 62544 AUKENTUCKY 583,089 22828 ‘MISSISsiPP! 486,861 56,279 NORTH CAROLINA 785,083 19,929 ‘SOUTH CAROLINA 431,083 7212 TENNESSEE 788,231 771638 CHICAGO: REGION V 5,237,908 811.827 ILLNO'S 4,919,140, 92,728 “INDIANA ‘506, 829 149,162 MICHIGAN 1,129,028 78,720 MINNESOTA "406.491 43.734 ‘OHIO 292,700, {WISCONSIN 154,697 DALLAS: REGION Vi 560,282 ‘ARKANSAS 43,656 LOUISIANA, 87,397 NEW MEXICO 36.228 ‘OKLAHOMA 64,069 TEXAS 328,642 KANSAS CITY; REGION Vit 380,500 OWA 99,442 VKANSAS 19,342 ‘{MISSOURL 203,702 NEBRASKA 8.014 DENVER: REGION Vii 119,513 ‘COLORADO 53,059 {MONTANA 7,163 NORTH DAKOTA 405 ‘SOUTH DAKOTA 5188 yUTAR 30/608 WYOMING. 42,401 17.092 SAN FRANCISCO: REGION IK 5,085,146 647,905 ‘ARIZONA 402.212 33.685 CAUFORNIA 4,485,743 583,718 S/RAWAN 99,566 0 {YNEVADA 7,525 s0s72 SEATTLE: REGION X 1,008,457, 161772 ALASKA ‘57.540 6856 IDAHO 36,908 28575 OREGON 295,220 34423 WASHINGTON 568,673 113.918 {UMEDICAID STATISTICAL INFORMATION SYSTEM 2/MASSACHUSETTS BLIND ANO STATES DATA ARE ESTIMATED MAS = MAINTENANCE ASSISTANCE STATUS SOURCE: HOFA, BOMS, OPS, DIV OF MEDICAID STATISTICS 118TABLE 1, MEDICAID RECIPIENTS BY MAINTENANCE ASSISTANCE STATUS AND BY REGION AND STATE: FY1992 (cont) OTHER MEDICALLY COVERAGE ‘COVERAGE MAS NEEDY PRE 1988, FROM 1988 UNKNOWN, ‘ACL JORISDICTION Bass 514 2280, 048 2,503,202 ‘94,280 BOSTON: REGION! ‘20,544 221,310 57.275 1.297 ‘CONNECTICUT 45,753 87.221 158 0 MAINE 3,161 39903 23 605 MASSACHUSETTS 34/507 anit 36.587 0 NEW HAMPSHIRE 9671 11875 401 20 RHODE ISLAND nT 1,280 ° o VERMONT 4735 0 ° x2 NEW YORK: REGION i! 4,372270 49,249 98.827 5631 ‘NEW JERSEY 4909 49,249 43,903 5631 NEW YORK 705,002 0 53,727 0 PUERTO RICO 655,433 9 0 0 VIRGIN ISLANDS 6885 o 1,197 0 PHILADELPHIA: REGION ill 259,260 280,555, 128,249 22 DELAWARE: 0 5240 asst 02 DISTRICT OF COLUMBIA 6838 4409 612 0 MARYLAND 69.288, 42,785 4,080 0 PENNSYLVANIA 131/942 116.297 59,448 0 VIRGINIA 39,783 11788 16,564 0 WEST VIRGINIA 12,008 0 38,795 0 ATLANTA: REGION V 200,883 884,472 906,027 20577 ALABAMA 0 0 1211433 1241 FLORIDA 36747 145,990 265,426 0 GEORGIA 2674 ‘58,621 152,251 8191 KENTUCKY 83.238 37,654 72,648 11145 MISSISSIPPI 0 6,585 45,605 0 NORTH CAROLINA 58.671 198,050 96,838 ° ‘SOUTH CAROLINA 7.559 36.52 121,889 ° “TENNESSEE 81,999 143,720 26,908 9 CHICAGO: REGION V 536 992 332,837 331,351 6828 ILUNOIS, 228,767 432,801 28,360 0 INDIANA 0 86.903 ‘904 2.637 MICHIGAN 161,008 43.022 80,863 0 MINNESOTA, 1291301 4714 1,055 ° ‘OHIO 0 64,850 248,110 0 WISCONSIN, 16921 707 4259 4191 DALLAS: REGION VI 96,807 271,873 565,465, ° ‘ARKANSAS 29.088 59,981 11183, 0 LOUISIANA, 14128 90,208 68,268 ° NEW MEXICO 0 6572 12,605 0 OKLAHOMA, 14,860 1214 87,247 0 TEXAS. 38.035 113,902 418,192 0 KANSAS CITY: REGION Vit 46,384 60678 115,268 18737 IOWA 24591 623 0 748, KANSAS, 19.723 53,882 0 12882 MISSOURI 0 iss 92,909 2107 NEBRASKA 2,070 22.959 0 DENVER: REGION vil 32.057 are 59,628 3596 ‘COLORADO, 0 2161 19,704 0 MONTANA 5552 14413 0 1913 NORTH DAKOTA 20572 0 221 364 SOUTH DAKOTA 0 3413 16,135 o UTAH 5933, 18,054 22568 1418 WYOMING ° ° 0 301 SAN FRANCISCO: REGION Ik 913.907 249,076 1x8 ‘ARIZONA, o 141,945 154 ° ‘CALIFORNIA 909,620, 182,650 164,715 34.691 HAWalL 10297 20887 6323, 2116 NEVADA 3914 1918 1086 SEATTLE: REGION x 3739 98,959 79,102 1,569 ALASKA 0 0 12317 0 IDAHO. 0 1011 30.836 ° ‘OREGON 9763 53,740 94,125, 0 WASHINGTON 27.627 40,208 2014 1,563 119TABLE 2 MEDICAID RECIPIENTS BY BASIS OF ELIGIBILITY AND BY REGION & STATE: FY1992 TOTAL AGE 65 PERMANENTLY & st RECIPIENTS & OLDER BUND TOTAL ‘ALL JURISDICTIONS ‘31,180,004 ‘a 7aa.871 "36,250 BOSTON: REGION | 11827,002 "296,992 111951 ‘CONNECTICUT ‘316278 ‘95,102 281 Y/MAINE 162,440 22331 207 2IMASSACHUSETTS 686,205 105314 10,262 {INEW HAMPSHIRE 71,979 13,882 486 2IRHODE ISLAND 213388 39.660 521 {VERMONT 7502 10,643 38 NEW YORK: REGION 1 4.153410, 546,601 8407 NEW JERSEY 697,083 78,663, 1,200 NEW YORK 2.557701 399,784 3792 PUERTO RICO 885,405 wT 463 VIRGIN ISLANDS 13221 1143 6 PHILADELPHIA: REGION til 27677 319598 2867 {DELAWARE 60.606 5,358 DISTRICT OF COLUMBIA 108.514 visat MARYLAND 377,075 49,749 PENNSYLVANIA 1/398;394 12ar7t VIRGINIA 515,064 73411 WEST VIRGINIA 308,034 31,603 ATLANTA: REGION IV 5,399,821 763,121 VALABAMA, 466,918 69,882 FLORIDA 1,587,926 186,180, {GEORGIA ‘963,670 AVKENTUCKY 583,069 MISSISSIPPI 486,861 NORTH CAROUNA 785,043 ‘SOUTH CAROLINA 431,083 ‘TENNESSEE 735,231 CHICAGO: REGION V 5,287,908 ILLINOIS: 1,313,140, ‘VANDIANA '506,829 ‘MICHIGAN 4,429,028, MINNESOTA, 406,491 ‘OHIO 1,442,289 (WISCONSIN 440,198 DALLAS: REGION VI 3.619597 ‘ARKANSAS ‘320,875 LOUISIANA 702,268 NEW MEXICO 211,805 OKLAHOMA 360,099 TEXAS 2,024,558 KANSAS CITY: REGION vil 4.211.087 4MOWA. ‘78.828 “UKANSAS 226,991 25,268 ‘yMISSOURI 554,477 7as16 NEBRASKA 180,791 19,998 DENVER: REGION Vil 619,839 71,100 ‘COLORADO 258,690 30/821 {MONTANA 60,186 8.115 AINORTH DAKOTA, 37,068 10,713 ‘SOUTH DAKOTA 64.230 9751 {UTAH 137/264 ais 47 ANVYOMING 42.401 3,086 8 SAN FRANCISCO: REGION x 5,085,146 537,852 25,429 ‘ARIZONA 402212 23,258 693 S]GALFORNIA 4,485,783 491,685 24,308 HAAN 13817 18 {INEVADA 8.091 5 SEATTLE: REGION X 91,998, 1,688 ‘ALASKA 9,388 3 IDAHO 8783, 52 ‘OREGON 29,138 1,190 {WASHINGTON 50.639 365 {MEDICAID STATISTICAL INFORMATION SYSTEM _2/MASSACHUSETTS BLIND & STATES DATA ESTIMATED FOC = FAMILIES WITH DEPENDENT CHILDREN SOURCE: HCFA, BOMS, OPS, DIV. MEDICAID STATISTICS, 120TABLE 2 MEDICAID RECIPIENTS BY BASIS OF ELIGIBILITY AND BY REGION AND STATE: FY1992 (conn) OTHER, BASIS OF (CHILDREN ADULTS. TLE xk ELIGIBILITY REGION AND STATE UNDER 21 IN FOC RECIPIENTS UNKNOWN ALL JURISDICTIONS 15,199,818 "7040, 230 580,281 "96,350 BOSTON: REGION | ‘556,653 ‘944,290 7651 1/299 ‘CONNECTICUT 346,719 76,340 0 0 MAINE 88,082 37,387 5,567 605 MASSACHUSETTS, 285,507 152849 0 0 NEW HAMPSHIRE ‘33.815 18.206 0 330 RHODE ISLAND 7,193 43.452 1629 0 VERMONT 34342 21,058 455 364 NEW YORK: REGION II 2,185,503, 694,757 186,007 6,650 NEW JERSEY ‘327,381 175,240 ° 6.650 NEW YORK aaa 516,124 185,490 0 PUERTO RICO "709/146 0 0 o VIRGIN ISLANDS 7,265 3,403 515 0 PHILADELPHIA: REGION tl 1.302669 647,675 63.929 202 DELAWARE 31,687 13,558 1.925 202 DISTRICT OF COLUMBIA 35.504 24812 121 0 MARYLAND 182.487 702 5785 ° PENNSYLVANIA, 657,827 aegori 53.253, ° VIRGINA 244,340 114,415 0 ° WEST VIRGINA 431/004 93,117 248 0 ATLANTA: REGION IV 2,995,640 1.971192, 56.278 20,809 ‘ALABAMA 196,418 91,028 4574 1.248 FLORIDA 811,973 294,157 37,840 0 GEORGIA 412,087 198,838 8,191 KENTUCKY 257,105 11,168 MISSISSIPPI 321,010 0 NORTH CAROLINA 368,882 0 ‘SOUTH CAROLINA 198,972 0 TENNESSEE 367,198 0 CHICAGO: REGION V 2.621/881 6.828 ILUNOIS, (685,474 0 INDIANA 252,765, 2es7 MICHGAN ‘585,350 ° MINNESOTA 195,047 0 ‘OHIO 777458 ° WISCONSIN 1611387 4191 DALLAS: REGION VI 1,850,561 0 ARKANSAS: 97,549 0 LOUISIANA, 345,662 0 NEW MEXICO 328,312 0 OKLAHOMA 178.902 0 TEAS 1,100,196 0 KANSAS CITY: REGION vil 15,798 1OWA 748 KANSAS. 12,882 MISSOURI 2,108 NEBRASKA 0 DENVER: REGION Vil 3602 ‘COLORADO ° MONTANA 1513 NORTH DAKOTA, ‘370 SOUTH DAKOTA, ° UTAH 1418 WYOMING ‘201 ‘SAN FRANCISCO: REGION x aed "ARIZONA ° CALIFORNIA 34,69 HAWAIL 2116 NEVADA 11046 SEATTLE: REGION x 11569 ALASKA, 0 IDAHO ° ‘OREGON 0 WASHINGTON 1,569 121TABLE 3, MEDICAID RECIPIENTS BY TYPE OF SERVICE AND BY REGION AND STATE: FY1992 INPATIENT HOSPITAL NURSING TOTAL GENERAL MENTAL FACILITIES 1ON AND STATE ENTS. HOSPITAL HOSPITAL AVI ALL JURISDICTIONS: ‘31,150,004 5,789,650 77318 1.572.946 BOSTON: REGION! 1)827,022 "245.823, 33957 131,098 ‘CONNECTICUT 316,278 54.423 1,816 33.400 4IMAINE 162.440 97.431 '505 0271 2IMASSACHUSETTS: 686,235 96,721 1083, 50,420 AJNEW HAMPSHIRE: 71,179 ‘g9ee 228 6542 2IRHODE ISLAND 219,088 37.916 470 26,763 4/NERMONT 77,502 91388 7 3689 NEW YORK: REGION I 4,153,410, 1,008,791 16,788 165.928 NEW JERSEY 697,083 96,276 1423 39057 NEW YORK 2,887,701 483,172 1318 16871 PUERTO RICO 885,405 419,882 o 0 VIRGIN ISLANDS 221 861 ° o PHILADELPHIA: REGION i 2761.77 485,623, 8,695 147,328 ‘UDELAWARE 60,696 14278 0 2686 DISTRICT OF COLUMBIA 103,514 25,108 552 4955 MARYLAND 377.075 84,323 2,058 32328 PENNSYLVANIA 19981394 222.495 49% 70,100 VIRGINA, ‘515,064 97.811 ‘604 26876 WEST VIRGINIA 308,034 45812 438 10,425 ATLANTA: REGION IV 5,939,821 1,192,644 13,400 286,298 {IALABAMA 456.918 70,208 932 20.884 FLORIDA 1,892,926 247.883, 382 95220 {GEORGIA ‘363,870 458,802 0 38.252 AUKENTUCKY 108,233 3072 2541 MISSISSIPPI 91,253 565, 36501 NORTH CAROLINA 178,751 2371 34813 ‘SOUTH GAROLINA 197,805 4449 13,788 TENNESSEE 139,689 4429 4/502 CHICAGO: REGION V 917,494 13.344 944,086 HLUNOIS 3022 79019 ‘INDIANA 3.873 43.334 MICHIGAN 3335 43.875 MINNESOTA 3 40,143, OHIO 0 92710 {WISCONSIN 2,683 45,005 DALLAS: REGION VI 6748 120836 ARKANSAS 1347 21,243 LOUISIANA, 41921 36,615 NEW MEXICO 337 6637 OKLAHOMA 3,043 25,107 TEXAS 0 91,186 KANSAS CITY: REGION vi! 41211,087 3556 39.540 OWA ‘278,828 486 21,902 AIKANSAS 226,991 27.279 2.584 20217 symissount 554,477 17201 87 34.870 NEBRASKA 150,791 28,341 a9 12551 DENVER: REGION Vill 619,839 108,307 6581 35.981 ‘COLORADO 258,690 43971 1.338 14825 SIMONTANA| 60,188 9,004 724 5491 {INORTH DAKOTA 57,068 10256 1466 5630 ‘SOUTH DAKOTA 64230 14453 121 6182 UTAH 197/264 2.002 4216 41,523 WYOMING 42,401 742i 6 2290 ‘SAN FRANGISCO: REGION 5,085,148 781,587 Tao ‘ARIZONA 402212 92,701 664 13,704 AICALFORNIA 4,485,743 662,141 603 198,059 “AIHAWAN 99,668 ‘9,758 ° 3.983 SINEVADA 75525 16,987 289 3.556 SEATTLE: REGION X 1,008,457 135,638 2733 44578 ‘ALASKA 57/540 9,085 Ca 1097 IDAHO 86.924 14,557 25 5143 ‘OREGON 235,800 44,631 388, s2010 {WASHINGTON 568.673 67,385 1,658 25.328 {MEDICAID STATISTICAL INFORMATION SYSTEM 2/MASSACHUSETTS BLIND & STATES DATA ESTIMATED 3/INCLUDES INTERMEDIATE CARE FACILITIES (ALL OTHER) & SKILLED NURSING FACILITIES 122TABLE 3. MEDICAID RECIPIENTS BY TYPE OF SERVICE AND BY REGION AND STATE: FY1992 (conn) HOME PRESCRIBED FaMILy REGION AND STATE HEALTH DRUG: PLANNING __EPSDT ‘ALL JURISDICTIONS: 926,419 22069,576 2,588,658 496,437 BOSTON: REGION 95,618 | 1.076072 204,255 185,443 ‘CONNECTICUT 39.179 "e438 23157 98,472 MAINE 8772 © 125253, 16054 17.836 MASSACHUSETTS: 48.197 503,17 14154 91,848 NEW HAMPSHIRE 3725 53,926 7849 6,908 RHODE ISLAND 15903 109.810 9176 23,886 VERMONT 3752 59,385 7.673 495, NEW YORK: REGION I! 186,150 2,956,642 260/643 974,064 ‘NEW JERSEY 28,562 S50,556 ‘39.449 | 46,092 NEW YORK 187,588 1,790,354 220518 927.557 PUERTO RICO 0 0 0 0 VIRGIN ISLANDS: 0 6732 ers 418 PHILADELPHIA: REGION it s2574 1,959,122 193,76 389,196 DELAWARE 2646" 43,434 DISTRICT OF COLUMBIA 2773 64,038 MARYLAND. 10,169 280,191, PENNSYLVANIA 17455 946,314 VIRGINA, 17,189 381,893 WEST VIRGINA, (3287312 ATLANTA: REGION IV 4,459,600 ‘ALABAMA ‘350,933 FLORIDA 1088 225, GEORGIA, ‘694,862 KENTUCKY 39620 457,708 MISSISSIPPI 4781 396.229, NORTH CAROLINA s0g79 548,589 ‘SOUTH CAROLINA 9927 913.928, TENNESSEE 12887 608.456 CHICAGO: REGION V 1811403 3.828.209 TLUINOIS 32078 1,001,795 INDIANA 5166 998.733, MICHIGAN, oer saaste MINNESOTA. 36485 2B1,828, OHIO. 24997 997,501 WISCONSIN 34643 318738 DALLAS: REGION Vi 105,148 2,801,687 ‘ARKANSAS 16348 244.092 LOUISIANA, 11139544404 NEW MEXICO 2707 197,935 ‘OKLAHOMA 121068 260,537 TEXAS 62990 1.61479 KANSAS CITY: REGION vil 36933 ‘999,740 IOWA 13068 214,590 KANSAS. 5316 162078 MISSOURI 14281 497,551 NEBRASKA, 4318 118523 DENVER: REGION Vil 21007 441,720, ‘COLORADO 103300 187212 MONTANA 60342031 NORTH DAKOTA 3188 93,160. ‘SOUTH DAKOTA 2008 © 41,786 UTAH 4017 102578 ‘WYOMING 864 Ba,953 ‘SAN FRANC'SCO: REGION Ix 42.931 3.485,607 "ARIZONA, 6072 22,092 CALIFORNIA 34,497 9,936,972 925,650 HAWAIL 778,168 3,582 NEVADA 4715 49.975 ° SEATTLE: REGION X 29927 © 733,175 99.997 ALASKA 2486 33,188 2.548 IDAHO. 2960 63215 6257 OREGON 19.899 197.649 7,620 WASHINGTON 4572 499,123 raz72 {MEDICAID STATISTICAL INFORMATION SYSTEM 2/MASSACHUSETTS BLIND & STATES DATA ESTIMATED INCLUDES INTERMEDIATE CARE FACILITIES(ALL OTHER) AND SKILLED NURSING FACILITIES 123TABLE 9, MEDICAID RECIPIENTS BY TYPE OF SERVICE AND BY REGION AND STATE: FY1992 (conn AURAL OTHER SERVICE IEGION AND STATE HEALTH CARE UNKNOWN, ALL JURISDICTIONS 7671636941468 2,774 BOSTON: REGION | 211583 402,204 «73 ‘CONNECTICUT 4187407 0 MANE. 11481 _49;260 a3 MASSACHUSETTS 184,188, 0 NEW HAMPSHIRE 1856 11,749 9 RHODE ISLAND 3212 46,700 ° ‘VERMONT 5293 22,900 ° NEW YORK: REGION il 0 34882 o NEW JERSEY 0 137970 9 NEW YORK o 695817 ° PUERTO RICO 0 0 0 VIRGIN ISLANDS 0 1.065 ° PHILADELPHIA: REGION il 112951 739.283 4 DELAWARE: 0 BaIS 4 DISTRICT OF COLUMBIA 046.696 0 MARYLAND Te 107,134 ° PENNSYLVANIA, 63.426 411/023, ° VIRGINIA ‘747 74.761 0 WEST VIRGINIA 48.428 65.284 ° ATLANTA: REGION IV 209782 1.918228 2111 ‘ALABAMA ‘99454 88,473 ° FLORIDA 85.628 317.885, 0 GEORGIA 1,983 (236.049, ° KENTUCKY 5779 165,102 2.111 MISSISSIPPI 25601 156,522, 0 NORTH CAROLINA 40606 134,147 9 ‘SOUTH CAROLINA 7419 88.908 0 TENNESSEE S92 131,044 o CHICAGO: REGION V 94479 1,340,963 2 TLUNOIS: 12434 "274519 0 INDIANA 0 147215 23 MICHIGAN 5405 197,607 0 MINNESOTA | 114,866 0 OHIO. 19615 451,204, ° ‘WISCONSIN 3005 185,152 ° DALLAS: REGION VI 74,790 608.270 o ‘ARKANSAS 2200 20,803 ° LOUISIANA, 0 222.933, ° NEW MEXICO 27907 0.118 ° OKLAHOMA, 4,288 42.912, ° TEXAS 43.995 211,504 0 KANSAS OFTY: REGION Vil 13188 221,365 0 JOWA 2028 "79,363, 0 KANSAS, 4688 30/208 ° ‘MISSOURI 6472 90,065, 0 NEBRASKA 0 21,682 0 DENVER: REGION Vit 38,284 188,694 2 COLORADO 25844 68,383 0 MONTANA 0 14504 a NORTH DAKOTA 5565 13353 2 ‘SOUTH DAKOTA 5850 11,621 0 UTAH 97 24,604 ° WYOMING 38 (26,200 0 SAN FRANCISCO: REGION IX 234,989 1,019,280 155 ‘ARIZONA 0 148,830 0 CALIFORNIA 234,369 849,954 ° HAWAIL 0 12739 0 NEVADA 0 14357 155 SEATTLE: REGION X 7757 304361 0 ‘ALASKA 420” 16.884 0 IDAHO. 1448 15,289 ° ‘OREGON 2026 9852 ° WASHINGTON 3863 180.236, 0 124‘TABLE 9, MEDICAID REC:PIENTS BY TYPE OF SERVICE AND BY REGION AND STATE: FY1992 (CONT) lor MENTALLY PHYSICIAN _ DENTAL 1D STATE RETARDED SE SEA ‘ALL JURISDICTIONS 151.922 21,682,875 5,717,202 BOSTON: REGION? 8.762 ‘944,998 496,817 ‘CONNECTICUT c 396009 110,542 ‘MAINE 109443 44.642 MASSACHUSETTS 470,178 258,644 NEW HAMPSHIRE 43532 17,758 RHODE ISLAND 62268 40,356 ‘VERMONT 2969 27.875 NEW YORK: REGION i! 1,921/685 980,827 NEW JERSEY ‘476898 204,795 NEW YORK 1444521 779,968 PUERTO AICO ° 0 VIRGIN ISLANDS 287 2,088 :: REGION Ii) 19151 1,859,070 568,889 490374837175 DISTRICT OF COLUMBIA 67456515 12,842 0 1083 270,667 58,145, PENNSYLVANIA 7at4 829,183 993,159, 2830 426242 74,109 WEST VIRGINIA 701 238.980 83,459, ATLANTA: REGION IV 2004 4678.028 1,126,372 ‘ALABAMA, 1,298 "987,983" 56,969 FLORIDA 33807 1,195,183 284,115 GEORGIA 1,760 "720,805 213,297 KENTUCKY 11301 468,020 151,519 MISSISSIPPI 1,889 406,789 29,120 NORTH CAROLINA 4537 636,590 179,578 ‘SOUTH GAROLINA 3448 345,063 87,893, TENNESSEE, 2501 606,249 144.481 CHICAGO: REGION V 41817 9,728,767 1,142,721 ILLINOIS 19281 1,003,285 98 INDIANA, 6065 "355,310 174,599, WICHIGAN 3128 859,643 311,515. MINNESOTA, 5678 285319 198012 ‘OHIO 8650 1010,661 390,399, WISCONSIN 4765 ‘210549 128,218 DALLAS: REGION VI 25,158 2970732 528,643 ‘ARKANSAS: 1942 "2511284 42.019 LOUISIANA, 619 562952 140,016 NEW MEXICO 858175954 30,482 OKLAHOMA 2881 267,160 61.111 TEAS 18457 19931982 255,015, KANSAS CITY: REGION vii 8790 "826,885 334,073, IOWA 2143 192,365 109,624, KANSAS. 2052 169256 35,492 MISSOURI 4874 335,181 134,179 NEBRASKA 721 130,116 54838 DENVER: REGION Vil 7282 470.487 197,583, ‘COLORADO 11000 196,295 46,580 MONTANA 21347673 19,025, NORTH DAKOTA 7 41837 18,730, SOUTH DAKOTA sa2 44208 7,551 UTAR 468 111680 «39,972 WYOMING 6 29088 5,725 SAN FRANGISCO: REGION IX 10,484 9,599,695 146,696 "ARIZONA 481 "249,185 45,381 ‘CALIFORNIA, 9,895 9,153,721 43,961 HAWAI 169" 80,480 38,561 NEVADA 23956479 38,773 SEATTLE: REGION X 1,785 748.008 256.641 ‘ALASKA 90 41,181 17,385 IDAHO. 5827405724582 ‘OREGON mm wre (38487 WASHINGTON 376 480,199 176,227 125TABLE 3, MEDICAID RECIPIENTS BY TYPE OF SERVICE AND BY REGION AND STATE. FY1992 (cont) OTHER OUTPATIENT — CUNIC LAB ANO STA \CTTMIONER HOSPITAL SERVICES __X-RAY ‘ALL JURISDICTIONS 4,724,802 15,167,471 4,127,738 11 800.416 BOSTON: REGION | 282310 793987 “a11103 343.912 ‘CONNECTICUT e932 193588 «6222857522 MAINE 34172 84710, 703 75,883 MASSACHUSETTS. 100728 350,630 190,716 148,027 NEW HAMPSHIRE 9561 35,687 10,082 31,783 RHODE ISLAND 9028 91,001 0 23376 VERMONT 140338351 73726781 NEW YORK: REGION tt 557,347 2,088,351 628,907 1,151,378 NEW JERSEY 119961 "365,954 92,503 “315,764 NEW YORK 487386 1,257,328 536,403 835,290 PUERTO RICO 0 465,723 0 0 VIRGIN ISLANDS Oo 9948 0 a4 PHILADELPHIA: REGION I 319.618 1,407,726 346,461 851,877 DELAWARE 569" 32320 «762317819 DISTRICT OF COLUMBIA 4196 510588558 (98,386 MARYLAND 25418 185.845 68,065 99,782 PENNSYLVANIA 165,785 678,300 132.215 VIRGINIA, 561886 295,071 93,063 WEST VIRGINIA 62524 165,332 95,996 ATLANTA: REGION IV 760,235 2912132 617,798 ‘ALABAMA 50,734 "1821538 9.58 FLORIDA 125552 668.844 © 99,806 GEORGIA 113381 475,817 36,069 KENTUCKY 99,198 313.902 98,490 MISSISSIPPI 7.669 223250 19,053. NORTH CAROLINA 116,288 401,903 108,68 ‘SOUTH CAROLINA 9,673 195,878 101,853 ‘TENNESSEE 114,740 449,202 124,284 ‘CHICAGO: REGION V 941,151 2,627,645 966,808 TLUNOIS, 100/879 INDIANA 204,849 MICHIGAN, 188,591 MINNESOTA 61,002 ‘OHIO 176,861 WISCONSIN, 234,722 DALLAS: REGION vi 227168 ‘ARKANSAS 40,650, LOUISIANA 100088 360,737 61,077 NEW MEXICO 18,775 108,127 28.991 ‘OKLAHOMA, 53,054 148,872 (26,742 TEXAS 383,570 950,462 _ 69,704 KANSAS CITY: REGION Vl 213,151 585,851 392,531 TOWA 68403 136,007 16,353 KANSAS, 2771 63.077 56,898 MISSOURI 2466 295,633 207,991 NEBRASKA posit 71,184 11,349 DENVER: REGION Vil 2853 234578 65,073 ‘COLORADO 19253 12,718 28,597 MONTANA 13073 25,934 4.715 NORTH DAKOTA 12798 4911 S.121 ‘SOUTH DAKOTA 12054 3.164 9.697 UTAH 2627 84622 12,799 WYOMING 5058 16831 4.208 SAN FRANG'SCO: REGION IK 812.716 2.911.180 543.115 ‘ARIZONA 18327 "181/631 52.980 CALIFORNIA 775,112 2052753 475,064 HAWAlL 13097 "25,408 11,230 NEVADA 73,180 41.934 .aat SEATTLE: REGION X 145096 457208 128,782 ‘ALASKA 9605 24690 4.310 IDAHO 9.956 525704 OREGON 22670 118978 33,839 WASHINGTON 102,865 27180884929 126TABLE 4. CATEGORICALLY NEEDY MEDICAID RECIPIENTS WHO RECEIVE CASH PAYMENTS BY BASIS OF ELIGIBILITY AND BY REGION AND STATE: FISCAL YEAR 1992 TOTAL AGE 65 PERMANENTLY & t ATE |ENTS_AND OLDER BLIND TOTAL DISABLED ‘ALL JURISDICTIONS 78803,045 387 3,265,037 BOSTON: REGION | "184,728 ‘CONNECTICUT u {MAINE 13880 MASSACHUSETTS. Y/NEW HAMPSHIRE 2IRHODE ISLAND $NERMONT NEW YORK: REGION I \{YNEW JERSEY NEW YORK PUERTO RICO VIRGIN ISLANDS PHILADELPHIA: REGION i DELAWARE DISTRICT OF COLUMBIA MARYLAND PENNSYLVANIA VIRGINIA WEST VIRGINIA ATLANTA: REGION IV YALABAMA FLORIDA 971,881 GEORGIA 123.205 SKENTUCKY 102,732 MISSISSIPP! 84,990 NORTH CAROLINA 38.849 SOUTH CAROLINA 54,267 ‘TENNESSEE 192,255 CHICAGO: REGION V 412,004 ILUNOIS 140,877 {INDIANA 25,806 MICHIGAN 125,050 MINNESOTA 27,922 ‘OHIO 17.458 ‘{JWISCONSIN, 1447 78.451 DALLAS: REGION VI 7921 972318 ‘ARKANSAS 1247 60,484 LOUISIANA i601 84,165 NEW MEXICO ‘347 23.560 ‘OKLAHOMA 822 33.079 TEXAS 3904 171,030 KANSAS CITY: REGION Vit 11739 61,333 sfOWA 524 30,437 KANSAS 107 ¥7,082 ‘MISSOURI 9371587 NEBRASKA 171 12207 DENVER: REGION Vill 480 58,674 ‘COLORADO 136 25,358 {MONTANA 6 (O5A7 NORTH DAKOTA 2% 4,906 ‘SOUTH DAKOTA 18581068 A)UTAK (7,965, WYOMING ‘993 7 2792 SAN FRANCISCO: REGION IX 912898 23,948 597,200 ‘ARIZONA, 10373 635 39,102 “CALIFORNIA 297.997 23,148 555,798 S/HAWAII 838 2 ‘350 {NEVADA 3,624 174,512 SEATTLE: REGION X 29318 4,230 ag,402 ALASKA 1038 59 3,295 IDAHO 4,376 24 3,983 OREGON, 10,228 eet 16,845, {WASHINGTON 16576 288 85,279 {JMEDICAID STATISTICAL INFORMATION SYSTEM 2/MASSACHUSETTS BLIND & STATES DATA ESTIMATED. AFDC = AID TO FAMILIES WITH DEPENDENT CHILDREN, 127TABLE 4, CATEGORICALLY NEEDY MEDICAID RECIPIENTS WHO RECEIVE CASH PAYMENTS BY BASIS OF (CONT) "ELIGIBILITY AND BY REGION AND STATE: Fr1992 ‘AFDC. Basis OF CHILDREN AFDC ELIGIBILTY STATE, UNDER 21_ADULTS UNKNOWN ALL JURISDICTIONS 9,480,751 — 4,447,149 7 BOSTON: REGION 487,003 258,774 ° CONNECTICUT 111955 87.235 0 MAINE 4238924165 0 MASSACHUSETTS 204268 113,959 9 NEW HAMPSHIRE 26,127 10,0841 0 RHODE ISLAND 82723 41,002 o VERMONT. 19156012342 0 NEW YORK: REGION tI 1,990,520 486.27 0 ‘NEW JERSEY Ber216 118,70 0 NEW YORK 891,796 365,236 o PUERTO RICO 188,702 0 0 VIRGIN ISLANDS: 2806001271 0 PHILADELPHIA: REGION 846,165. 499.757 0 DELAWARE: 21,650 o DISTRICT OF COLUMBIA 46.975 ° MARYLAND 119,238 0 PENNSYLVANIA, 494.919 ° VIRGINIA, 130815 0 WEST VIRGINIA 0 ATLANTA: REGION IV ° ALABAMA ° FLORIDA ° GEORGIA 0 KENTUCKY ° MISSISSIPPi ° NORTH CAROLINA ° ‘SOUTH CAROLINA 0 TENNESSEE ° CHICAGO: REGION V 0 TLINOIS 0 INDIANA ° MICHIGAN ° MINNESOTA ° ‘OHIO ° WISCONSIN w1414 49.752 ° DALLAS: REGION Vi 100131856 450,286 ° ‘ARKANSAS 63,902 (25,28, ° LOUISIANA, 213,885 89,696 ° NEW MEXICO 94,669 29,495, ° OKLAHOMA 112583 44.976 0 TEXAS 831,417 280,826 0 KANSAS CITY: REGION Vl 327,820 181,060 1 1OWA, 71298 41,179 9 KANSAS 85916 36/068 0 MISSOURI 158455 86,404 1 NEBRASKA 32163 17,371 0 DENVER: REGION Vit 182613 88,377 8 ‘COLORADO 87923 43,948 0 MONTANA. 19682 3.167 0 NORTH DAKOTA 132787387 6 ‘SOUTH DAKOTA 15632 7/820, 0 UTAH 31702 19,428 ° WYOMING 1433896 g27 ° SAN FRANCISCO: REGION IX 1,976,968 742,205 0 ‘ARIZONA 115585 60,767 ° CALIFORNIA, 4,198,629 650,623 0 HAWAII 40.098 18577 0 NEVADA 22458 12,508 0 SEATTLE: REGION x 398880 174,835 ° ALASKA 22.487 11,488, 0 IDAHO. 1685271487 ° ‘OREGON 101,384 53.821 ° WASHINGTON 199,147 102,069 ° 128TABLE 6, CATEGORICALLY NEEDY MEDICAID RECIPIENTS WHO DO NOT RECEIVE CASH PAYMENTS BY BASIS OF ELIGIBILITY AND BY REGION AND STATE: FY1992 TOTAL AGE 65 PERMANENTLY & REGION AND STATE REGIPIENTS & OLDER _BLIND_TOTAL DISABLED ‘ALL JURISDICTIONS 9811808 606995 5,240 440,302 BOSTON: REGION | 155,783 82.218 «877 15,982 ‘CONNECTICUT 13945 ‘452 5 710 {MAINE 46851 12073 9 4745 2IMASSACHUSETTS 3609738592151 1/301 {NEW HAMPSHIRE. y561 6741 152 2IRHODE ISLAND 14508 5,098 54 {VERMONT 28751 3998 6 NEW YORK: REGION tt 203263 96,170 93 ‘INEW JERSEY 103507 36,138, 30 NEW YORK 99514 32 3 PUERTO RICO ° 0 0 VIRGIN ISLANDS 282 ° ° PHILADELPHIA: REGION 957.942 65,648 88 ‘{IDELAWARE 6519 4 3 DISTRICT OF COLUMBIA 10279 852 1 MARYLAND 23.997 Bat 1 PENNSYLVANIA 221,308 50,728 6 VIRGINIA 48035 6,448 al WEST VIRGINA 47908 7247 6 ATLANTA: REGION IV 412981 66,038, 315 {ALABAMA 52592 18,122, 30 FLORIDA 116160102 3 {GEORGIA e244 0 ° KENTUCKY 26 6964 23 MISSISSIPPI 5427914072 7 NORTH CAROLINA 19923 1,050 it ‘SOUTH CAROLINA 7212 239 9 TENNESSEE 77633 25,168 222 CHICAGO: REGION V eiger 173929 1,889 HLUNO'S, ‘92,724 ‘482 4 {INDIANA 149162 43,63 463 MICHIGAN 73720 12,065 11 MINNESOTA, 43734 3,570 58 ‘OHIO. 292780 74.413 eta AWISCONSIN. 184697 99,767 20 ©8823 DALLAS: REGION Vi 560292 68,983 15521572 ‘ARKANSAS 4gesé 19,418 383556 LOUISIANA, 87397 26.277 32 9.498 NEW MEXICO 36.208 112 3 207 OKLAHOMA, 64369 21,120 2s 6.880 TEXAS sone © “Dosa 2 4451 KANSAS CITY: REGION Vil 380,500 109,837 299 81,889 IOWA 99.442 20,445 73 3875 {/KANSAS 19342 2 0 38 {MISSOURI 203702 72.492 190 74,739 NEBRASKA 58014 10978 363.596 DENVER: REGION VI 119513 6.939, 36 13,081 ‘COLORADO 2310 2 6611 S/MONTANA Boat 101,756 {NORTH DAKOTA 330 3 ‘303 ‘SOUTH DAKOTA 351 1 67 4yUTAH 34 1 1286 WYOMING 2,033 11/098 ‘SAN FRANCISCO: REGION Ix 20.348 415 161059, ‘ARIZONA 33,645, 260 8 318 {CALIFORNIA S371 15,818 160-7478 {PHAWAIL 0 0 0 0 SINEVADA gosr2 4272 237 7,766 SEATTLE: REGION x wey772 32,129 108 18.332 ALASKA 6,856 203, 0 74 IDAHO 26575 6057 2 8.497 OREGON, 44,423 0 ° 0 {WASHINGTON 113.918 25.869 73 TTB 41/ MEDICAID STATISTICAL INFORMATION SYSTEM 2/MASSACHUSETTS BLIND AND STATES DATA ESTIMATED FDC = FAMILIES WITH DEPENDENT CHILOREN 129‘TABLE 5. CATEGORICALLY NEEDY MEDICAID RECIPIENTS WHO DO NOT RECEIVE CASH PAYMENTS BY BASIS (CONT) OF ELIGIBILITY AND BY REGION AND STATE: FY1902 OTHER BASIS OF CHILDREN ADULTS TITLE XK ELIGIBILITY JON AND ST IN FDC_AECIPIENTS UNI ‘ALL JURISDICTIONS ‘Sea 18 890,169 947,495 a BOSTON: REGION | S994 37,643 ° ‘CONNECTICUT 6393 5,840 ° MAINE 14588 9.860 0 MASSACHUSETTS 17608 11,178 ° NEW HAMPSHIRE 47 1660 0 RHODE ISLAND. 187 ‘960 0 VERMONT 44192 8,136 ° NEW YORK: REGION it saier 23,174 1 NEW JERSEY 33889 (2814 i NEW YORK 4 ‘356 ° PUERTO RICO 0 9 ° VIRGIN ISLANDS 238, 4 0 PHILADELPHIA: REGION = 111208 1,211 0 DELAWARE 4233 1,953 ° DISTRICT OF COLUMBIA 4910 ‘928 ° ‘MARYLAND 170764495 0 PENNSYLVANIA, 57828 90,665 ° VIRGINIA 0 37,833 ° WEST VIRGINIA 271598399 0 ATLANTA: REGION IV ws907 75,955 8 ‘ALABAMA 17113 | 8282 a FLORIDA 209327488 0 ‘GEORGIA 43.376 19,168, 0 KENTUCKY 8551 6.376 0 MISSISSIPPI 38.072 "23 0 NORTH CAROLINA 10.540 258 ° ‘SOUTH CAROLINA 432 2.848 o TENNESSEE 25599 11,848 0 CHICAGO: REGION V 250498 144,193 0 TLUNOIS, 62270 33,715, 0 INDIANA 35501 5.728, 0 MICHIGAN z9g70 23.407 0 MINNESOTA, 19297 12,728 ° OHIO. 52873 42.378 ° WISCONSIN, 40627 26.238, 0 DALLAS: REGION Vi 347893 114,028 ° ‘ARKANSAS 0 12.993, a LOUISIANA 48530 5,000, 0 NEW MEXICO 32.998 2910 ° OKLAHOMA 92350 4013, ° TEXAS 296023 a9,112 ° KANSAS CITY: REGION Vil tor032 68.953 ° IOWA 42008 = 22.128 ° KANSAS 12190 7.151 ° Missouri were 25,607 o NEBRASKA 16024 14,069 0 DENVER: REGION Vil 72278 2182 0 ‘COLORADO 27384 13.967 0 MONTANA ‘988 196 ° NORTH DAKOTA aia 1,868 o SOUTH DAKOTA 3603 1.168 o UTAH 23,297 1/028, 0 WYOMING 91844196 0 SAN FRANCISCO: REGION X 264,764 284,416 61,933, 0 ‘ARIZONA 25482 7,080 0 0 CALIFORNIA, 225253 274655 60,350 0 HAWAIL 0 0 0 0 NEVADA 340032681 1,583 0 SEATTLE: REGION X S0679 38,774 23,755, 0 ALASKA 5918 651 ° ° IDAHO 7694 9782 ear 0 OREGON 9376 5047 0 0 WASHINGTON 27731 29.334 23,128 ° 130TABLE 6, MEDICALLY NEEDY MEDICAID RECIPIENTS WHO DO NOT RECEIVE CASH PAYMENTS BY BASIS OF ELIGIBILITY AND BY AEGION AND STATE: FY1992 TOTAL AGE 65 AND. & OLDER, ‘ALL JURISDICTIONS: 768353 BOSTON: REGION | 43411 ‘CONNECTICUT 18,128 MAINE 2IMASSACHUSETTS {/NEW HAMPSHIRE, 2IRHODE ISLAND {NERMONT NEW YORK: REGION 1 4,972;270 INEW JERSEY 4949 NEW YORK 705,002 PUERTO RICO 685,483 VIRGIN ISLANDS 6.885 PHILADELPHIA: REGION i 259.260 {DELAWARE ° DISTRICT OF COLUMBIA 6838 MARYLAND 69.288 PENNSYLVANIA, 191/942 VIRGINIA, 39,783 WEST VIRGINIA 12.008 ATLANTA: REGION IV 240,983 {YALABAMA 0 FLORIDA 36747 {IGEORGIA 2674 {VKENTUCKY 53.238 MISSISSIPPI ° NORTH CAROLINA 58671 ‘SOUTH CAROLINA 7553 TENNESSEE 81,990 CHICAGO: REGION V 596 992 ILLINOIS, 229,767 ‘VINDIANA ° MICHIGAN 161,008 MINNESOTA 129,301 ‘OHIO 0 0 0 WISCONSIN 16921 2 3,188 DALLAS: REGION VI 95.807 2 © Bors ARKANSAS 29,088 0 1,650 LOUISIANA, 14,128 6 38i7 NEW MEXICO 0 ° 0 OKLAHOMA 14,550 8 2482 TEXAS 33,035, 0 0 KANSAS CITY: REGION vi 46384 16761 2B Bae snowa 245a1 7316 22 4988 AVKANSAS 1872038295, 5 2671 “UMISSOURI 0 ° 0 ° NEBRASKA 2.070 550 1 585 DENVER: REGION Vil 9208711811 2 8554 ‘COLORADO 0 0 0 ° MONTANA 5852 4.020 1 1818 {NORTH DAKOTA 2572 6512 2 1799 ‘SOUTH DAKOTA 0 0 0 0 YUTAR 59331279 182440 AMYONING 0 0 9 0 SAN FRANCISCO: REGION IX 913,927 116.954 1,005. 46,744 ‘ARIZONA 0 0 0 0 {}CAUFORNIA 903,680 1158081002 46,398 1/HAWAN 10297 1,455 3 346. AINEVADA, 0 0 0 ° SEATTLE: REGION X 37,990 9,185 3B O4S ‘ALASKA 0 0 ° 0 IDAHO 0 ° ° ° ‘OREGON, 9763-2219 7% 2870 WASHINGTON 2782T —6.936 a 7.256 4 MEDICAID STATISTICAL INFORMATION SYSTEM 2/MASSACHUSETTS BLINO & STATES DATA ESTIMATED FDC = FAMILIES WITH DEPENDENT CHILDREN 131‘TABLE 6. MEDICALLY NEEDY MEDICAID RECIPIENTS WHO DO NOT RECEIVE CASH PAYMENTS BY BASIS OF (CONT) ELIGIBILITY AND BY REGION AND STATE: FY1992 ‘OTHER _BASIS OF CHILDREN ADULTS TITLE. XIX ELIGIBILITY REGION AND STATE. INDER 21 IN FDC RECPIENTS UNKNOWN ‘ALL JURISDICTIONS (698.092 655,902 142,628 2 BOSTON: REGION | 25569 21/524 0 2 ‘CONNECTICUT 12643 (013 0 0 MAINE 4,953 520 ° 0 MASSACHUSETTS: Tit 10214 ° ° NEW HAMPSHIRE 2ose 1,281 0 0 RHODE ISLAND 41804 ‘968 0 0 VERMONT 590 580 0 2 NEW YORK: REGION I 746,787 128.843 88,432 0 NEW JERSEY 4.353 10 0 ° NEW YORK 218494 127.247 87,917 0 PUERTO RICO 520,444 ° ° ° VIRGIN ISLANDS. 3505 1,588, 515, ° PHILADELPHIA: REGION it 1547 84745 11,081 ° DELAWARE 0 0 0 ° DISTRICT OF COLUMBIA 19391622, a2 0 MARYLAND 19906 9.6205 786 0 PENNSYLVANIA 64.980 99.957 5813, o VIRGINA, 7,505, 59 0 0 WEST VIRGINIA ggi7 3491 0 0 ATLANTA: REGION IV 95156 67,760 «8.581 ° ‘ALABAMA 0 0 9 9 FLORIDA 1277 1,698 4297 0 GEORGIA ‘903 41097 0 KENTUCKY 26,536 187 9 MISSISSIPPI ° ° ° NORTH CAROLINA 3473 9 9 SOUTH GAROLINA 2278 9 0 TENNESSEE 44444 0 ° ‘CHICAGO: REGION V 187519 9738 ° ILLINOIS 68.586 5 ° INDIANA ° 0 0 MICHIGAN 69.088 0 0 MINNESOTA 52.122 9731 0 OHIO. 0 0 0 WISCONSIN, 7722 2 ° DALLAS: REGION VI 30618 20,768 0 ‘ARKANSAS. 1178 20,068, 0 LOUISIANA 4286 0 Q NEW MEXICO 0 0 ° OKLAHOMA 621 698 0 TEXAS. 18897 19,498 0 0 KANSAS CITY: REGION VII 1098 6210 4,151 ° 1OWA, 34814333 3.851 0 KANSAS. 7208 1,524 0 ° MISSOURI 0 0 0 ° NEBRASKA 281 353 300 9 DENVER: REGION Vil Bari 4502 1,288 0 ‘COLORADO 0 0 0 ° MONTANA 2 mn 3 o NORTH DAKOTA 782 ©9282 1,008 ° ‘SOUTH DAKOTA 0 0 0 0 UTAH 951,199 2 0 WYOMING 0 0 0 ° SAN FRANCISCO: REGIONIX 481,381 267,833 ° 0 ‘ARIZONA 0 0 0 0 CALFORNIA 474,171 266610 0 0 HAWall Tam * 4.223 0 ° NEVADA 0 0 0 0 ‘SEATTLE: REGION X 9654 71838 1,279 ° ‘ALASKA, 0 0 0 ° IDAHO. 0 0 0 0 ‘OREGON 4318 1,088 a ° WASHINGTON 535 © 6800 1.279 0 132TABLE 7. MEDICAID RECIPIENTS OF OTHER COVERAGE GROUPS FROM PRE 1988 LEGISLATION BY SASIS OF ELIGIBILITY AND BY REGION AND STATE: FYI992 TOTAL — AGE 65 PERMANENTLY & REGION ANO STATE: RECIPENTS & OLDER BLIND TOTAL DISABLED ALL JURISDICTIONS 2: 3249 188,348 BOSTON: REGION | 221310 215 47,698 ‘CONNECTICUT 87.221 205 a2 MAINE: 19923 0 (3077 2IMASSACHUSETTS amit 017183 SINEW HAMPSHIRE 11875 10 ‘220 2IRHODE ISLAND 1,280 0 0 SIVERMONT 0 0 NEW YORK: REGION II 2 7,305, {NEW JERSEY 827395 NEW YORK 0 0 PUERTO RICO 0 ° VIRGIN ISLANDS 0 0 ° PHILADELPHIA: REGION Il 280,585 3 4,068 ‘JDELAWARE 5,240 0 tar DISTRICT OF COLUMBIA 4499 3 ‘600 MARYLAND 42.785 0 0 PENNSYLVANIA 116297 0 ass VIRGINA, 111,734 ° 0 WEST VIRGINIA 0 0 ° ATLANTA: REGION IV 684,472 2417 60,982 VALABAMA 0 0 0 FLORIDA 145,990 9 27,896 SIGEORGIA 55,621 2118 15,560 KENTUCKY 37.654 16 (29 MISSISSIPPI 65,585 0 5791 NORTH CAROLINA 198,050 275,347 SOUTH GAROLINA 36,852 24,109 TENNESSEE 143,720 0 0 CHICAGO: REGION V 332.837 48 8255 TLUINOIS 132,801 27787 \VINDIANA 86.943 5 ‘492 MICHIGAN, 43,022 ° 0 MINNESOTA 4714 1 6 OHIO. 64,850 ° ° {WISCONSIN 707 ° 0 DALLAS: REGION VI 271.873 123 18,985 ‘ARKANSAS 59,981 0 0 LOUISIANA ‘90,204 98 «4376 NEW MEXICO 8,572 301,045, OKLAHOMA 4216 0 0 TEXAS. 113,902 18 13504 KANSAS CITY: REGION Vil ‘60,674 3 7287 iNOW 639 ° 0 AIKANSAS 99,882 3 7,285 suMissouRl 6.159 0 2 NEBRASKA 0 0 0 DENVER: REGION Vit 97,041 8 5108 ‘COLORADO 2181 0 tr {MONTANA 14419 0 ° AINORTH DAKOTA 0 0 ° ‘SOUTH DAKOTA g41s 5,590 3 1825 UTAH 15054 4.187 5 asia {WYOMING 0 0 0 ° SAN FRANCISCO: REGION X 249,076 24,048, 4812764 ‘ARIZONA ato 12.531 4 3716 {/CAUFORNA ‘82,660 0 0 ° ‘STHAWAIL 20587 11,514 9 9,043, NEVADA 3914 3 0 5 SEATTLE: REGION X 94959 15018, 202 15,891 ALASKA 0 0 0 0 IDAHO 1011 0 ° 0 OREGON 53740 15,014 292 18,801 AWASHINGTON 40,208 9 0 0 {IMEDICAID STATISTICAL INFORMATION SYSTEM 2/MASSACHUSETTS BLIND AND STATES DATA ESTIMATED 133