State Pharmaceutical Assistance Program  (SPAP) Legislation & Policy Changes To Coordinate With & Supplement Part D: Issues, Possibilities & Challenges for HIV, Disabled & Other Patients

By Thomas P. McCormack; October 15, 2005

Several states passed legislation and/or regulations creating, altering or--in once case-- abolishing SPAPs in response to the coming implementation of Medicare Part D, especially to coordinating with and supplement drug coverage for those Low Income Subsidy (LIS)/”Extra Help” patients with incomes under 150% FPL.  

SPAPs can cover drugs not on individual Part D plans’ formularies; pay LIS/Extra Help patients’ co-pays, coinsurance, deductibles and premiums; do likewise for slightly “richer’ limited income patients (as some newly-created or adapted SPAPs will do); and---if they meet CMS standards—have such drug payments count toward True Out Of Pocket (‘TrOOP”) credit for moving patients over 150% FPL through and out of the donut hole and into Part D’s catastrophic coverage.

State- and local-level advocates—and especially advocates for HIV and other disabled patients—need to work now with state health officials administering (or establishing new) SPAPs to ensure that they cover the disabled equally (including those in their two year Medicare waiting periods) and effectively coordinate with, and supplement, Part D for all limited income patients. For example, “secondary” SPAP coverage is the easiest---and maybe the only effective---way to pay the otherwise unaffordable 15% coinsurance for those LIS/Extra Help patients with incomes between 135% and 150% FPL.

[See TII-SPAPs & ADAPs for whether, and to what extent, SPAPs covered the aged and disabled equally just before the developments listed below. That includes those states with SPAPs which have no developments listed below. TII-SPAPs & ADAPs  also offers persuasive data and arguments for urging state officials to now equally the disabled—including those disabled still in their two year Medicare waiting periods-- in those SPAPs which have excluded them. No states yet have any material up on their websites on these changes; but relevant state bill numbers, where available, are listed on Table 10, page 33, and elsewhere, in State Medicaid Actions-2005 of Thompson West’s Health Policy Tracking Service and under the state pharmaceutical issue icons on the health policy pages at www.ncsl.org .]

Alaska—created an aged-only SPAP to supplement Part D-- which excludes the disabled--- for those Medicare patients with incomes under 175% FPL. 

Hawaii—created a SPAP to supplement Part D---which covers both aged and disabled Medicare patients, but not those disabled still in their two year Medicare waiting periods. But the new SPAP has an income level of only 100% FPL—which is already the aged/disabled Medicaid income level in Hawaii---thus apparently making this new program a mostly empty, largely redundant exercise.

Indiana—authorizes the originally aged-only SPAP to coordinate with and supplement Part D, but without explicit mention of adding coverage of the disabled.

Kentucky---created an aged-only SPAP to supplement Part D—which explicitly excludes the disabled—for those Medicare patients under 150% FPL.

Michigan---abolished its aged-only SPAP, effective January 1, 2006.

Mississippi—drops (as already scheduled) its present coverage of all aged and disabled with incomes under about 135% FPL on January 1, 2006, but then on the same date simultaneously creates a “Medicare-patients-only” Medicaid income level of 150% FPL—thus excluding those disabled still in their two year Medicare waiting periods (who will have to have income under the much lower $569 monthly SSI level to get Medicaid).

Missouri---instructed its previously aged-only SPAP to coordinate with, and supplement, Part D coverage for SPAP eligibles—and it now explicitly includes the disabled (but it is unclear whether those disabled still in their two year Medicare waiting periods will be covered too).

Montana—created a SPAP to coordinate with, and supplement, Part D coverage for “all” (presumably including the disabled too) those Medicare patients those under 200% FPL—but it is unclear whether those disabled still in their two year Medicare waiting periods will be covered too.

Nevada-- instructed its previously aged-only SPAP to coordinate with, and supplement, Part D coverage for those under 225% FPL—and it now explicitly includes the disabled (but it is unclear whether those disabled still in their two year Medicare waiting periods will be covered too).

New Hampshire-- created a SPAP to coordinate with, and supplement, Part D coverage for “all” (explicitly including the disabled too) those Medicare patients those under 150% FPL—but it is unclear whether those disabled still in their two year Medicare waiting periods will be covered too. State health officials are explicitly given further regulatory authority.

New Mexico—reported as creating a “SPAP”, the actual state legislation may merely have authorized only a state-sponsored pharmacy discount or manufacturer PAP access-assistance program 

New York—authorized its aged-only SPAP (EPIC) to coordinate with, and supplement Part D---but a bill to extend coverage to the disabled died in the legislature.

Oregon---authorizes its originally aged-only SPAP---which might actually only be  a state-sponsored pharmacy discount or manufacturer PAP access-assistance program—to coordinate with, and supplement, Part D. There are no details as to coverage of the disabled--either on Medicare or in their two year waiting periods.

Note: Other states with SPAPs authorized coordination with, and supplementation of, Part D benefits—but no others are known to have made SPAP eligibility and coverage decisions.