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This document outlines critical topics regarding Home and Community-Based Services (HCBS) waivers, specifically focusing on formulary management, distribution channels, and the transition period for dual eligibles in Maryland. Key issues include the complexities of drug access for beneficiaries under Medicaid and Medicare, the role of HCBS waiver case managers, transportation barriers to accessing medications, and the risk of cost-shifting leading to increased institutional care. It emphasizes the need for effective planning and coordination to ensure that beneficiaries receive the medications necessary to maintain their community living.
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Part D: Implications to Home and Community-Based Waivers Charles Milligan, Executive Director Center for Health Program Development and Management University of Maryland, Baltimore County October 7, 2004
Areas to be Discussed • Formulary • Distribution channels • Transition period • HCBS Waiver Case Managers • Transportation • Risk of Cost Shifting/Institutionalization
Formulary • In FY 04, Maryland had 3,147 dual eligibles in two waivers. The top 10 Rx:
Formulary (con’t) • But that’s not the challenge. The challenge is that these 3,147 beneficiaries: • Received a total of 218,954 prescriptions in FY 04 (an average of 69.6 each); • Received 1,630 unduplicated medications; and • 399 separate medications were received by only ONE beneficiary each
Distribution Channels • Medicaid beneficiaries receive drugs from many sources;network issues will arise: • Over-reliance on mail-order for maintenance medications could cause problems
Transition Period • Will it be affordable, and considered not to be Medicaid fraud, for a state to dispense a 90 day supply of Rx in December 2005? • Even assuming auto-enrollment occurs, can/will Medicare plans approve all of the medications necessary, on a timely basis, for HCBS beneficiaries to remain in the community? • The number of people, and medications they take which must be transitioned, is extensive
Transition Period In FY 04, 68% of HCBS Dual Eligibles in Maryland Received Four or More Drugs Per Month
HCBS Waiver Case Managers • At present, HCBS waiver case managers generally do not need to coordinate access to Rx for HCBS beneficiaries across multiple vendors and formularies • If this role is incorporated into the job description of HCBS waiver case managers, it might change the caseload ratios and/or payment rates related to case management services
Transportation • Medicaid provides non-emergency transportation only to ensure access to Medicaid-covered benefits – in January 2006 this will not include Rx for dual eligibles • Thus, once Rx no longer is covered by Medicaid, HCBS waiver beneficiaries may have more difficulty simply picking up their medications
Risk of Cost Shifting and Institutional Care • For HCBS beneficiaries covered for Rx under Medicare, the financial incentive to spend funds on Rx to avoid institutional care will not be aligned across payors • For institutional residents covered for Rx under Medicare, the financial incentive to develop good community-based plans of care, which depend on Rx, will not be aligned across payors
Conclusion • The formularies AND how the Rx’s are distributed both matter • Access to medications may depend on transportation and case managers, where Medicaid will not have any formal role • Thoughtful transition planning will be difficult, and might benefit from 90 day supplies in 12/05, which might both be expensive and constitute Medicaid fraud • The financial incentives to spend money on Rx to keep people out of nursing homes are not aligned across payors
