Connecticut Seal

General Assembly

 

Raised Bill No. 6846

January Session, 2005

 

LCO No. 4217

 

*04217_______HS_*

Referred to Committee on Human Services

 

Introduced by:

 

(HS)

 

AN ACT CONCERNING IMPLEMENTATION OF THE MEDICARE PART D PROGRAM AS RELATES TO CONNPACE AND DUALLY ELIGIBLE BENEFICIARIES.

Be it enacted by the Senate and House of Representatives in General Assembly convened:

Section 1. (NEW) (Effective July 1, 2005) On and after the effective date of the Medicare Part D program established pursuant to Public Law 108-173, the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, no Medicaid prescription drug coverage shall be provided to a Medicaid recipient eligible for Medicare Part D for Medicare Part D Drugs, as defined in said act. Medicaid coverage will be provided for prescription drugs that are not Medicare Part D drugs, as defined in said act.

Sec. 2. Section 17b-490 of the general statutes is repealed and the following is substituted in lieu thereof (Effective July 1, 2005):

As used in sections 17b-490 to 17b-498, inclusive:

(a) "Pharmacy" means a pharmacy licensed under section 20-594 or a pharmacy located in a health care institution, as defined in subsection (a) of section 19a-490, which elects to participate in the program;

(b) "Prescription drugs" means (1) legend drugs, as defined in section 20-571, [(2) any other drugs which by state law or regulation require the prescription of a licensed practitioner for dispensing, except products prescribed for cosmetic purposes as specified in regulations adopted pursuant to section 17b-494, and on and after September 15, 1991, diet pills, smoking cessation gum, contraceptives, multivitamin combinations, cough preparations and antihistamines, and (3)] (2) insulin [,] and insulin syringes, [and insulin needles] (3) nonformulary Medicare Part D drugs, and drugs excluded from coverage under Medicare Part D, (4) any other drugs covered by Title X1X of the Social Security Act, for a full benefit dually eligible Medicare Part D beneficiary, and (5) any other drugs which by state law or regulation require the prescription of a licensed practitioner for dispensing, except (A) products prescribed for cosmetic purposes as specified in regulations adopted pursuant to section 17b-494, and (B) on and after September 15, 1991, diet pills, smoking cessation gum, contraceptives, multivitamin combinations, cough preparations and antihistamines unless provided for in subdivision (4) of this subsection;

(c) "Reasonable cost" means the cost of the prescription drug determined in accordance with the formula adopted by the Commissioner of Social Services in regulations for medical assistance purposes plus a dispensing fee equal to the fee determined by said commissioner for medical assistance purposes;

(d) "Resident" means a person legally domiciled within the state for a period of not less than one hundred eighty-three days immediately preceding the date of application for inclusion in the program. Mere seasonal or temporary residences within the state, of whatever duration, shall not constitute domicile;

(e) "Disabled" means a person over eighteen years of age who is receiving disability payments pursuant to either Title 2 or Title 16 of the Social Security Act of 1935, as amended;

(f) "Commissioner" means the Commissioner of Social Services;

(g) "Income" means adjusted gross income as determined for purposes of the federal income tax plus any other income of such person not included in such adjusted gross income minus Medicare Part B premium payments. The amount of any Medicaid payments made on behalf of such person or the spouse of such person shall not constitute income;

(h) "Program" means the Connecticut [pharmaceutical assistance contract to the elderly and the disabled program] Pharmaceutical Assistance Contract to the Elderly and the Disabled Program otherwise known as ConnPACE;

(i) "Pharmaceutical manufacturer" means any entity holding legal title to or possession of a national drug code number issued by the federal Food and Drug Administration;

(j) "Average manufacturer price" means the average price paid by a wholesaler to a pharmaceutical manufacturer, after the deduction of any customary prompt payment discounts, for a product distributed for retail sale;

(k) "Assets" means a person's resources, as defined by Public Law 108-173, the Medicare Prescription Drug, Improvement, and Modernization Act of 2003;

(l) "Low income subsidy" means a premium and cost-sharing subsidy for low-income individuals, as defined by Public Law 108-173, the Medicare Prescription Drug, Improvement, and Modernization Act of 2003;

(m) "Medicare Part D covered prescription drugs" means drugs that are included in Medicare Part D plan's formulary or are treated as being included in a Medicare Part D plan's formulary, as defined by Public Law 108-173, the Medicare Prescription Drug, Improvement and Modernization Act of 2003;

(n) "Medicare Part D plan" means a Medicare Part D plan, as defined by Public Law 108-173, the Medicare Prescription Drug, Improvement, and Modernization Act of 2003;

(o) "Gap in standard Medicare Part D coverage" means a drug obtained after a Medicare Part D beneficiary's initial coverage limit has been exceeded but before the beneficiary's annual out-of-pocket threshold has been met, as defined by Public Law 108-173, the Medicare Prescription Drug, Improvement, and Modernization Act of 2003; and

(p) "Full benefit dually eligible Medicare Part D beneficiary" means a person who has coverage for Medicare Part D drugs and is simultaneously eligible for full medical assistance benefits pursuant to section 17b-261, under any category of eligibility.

Sec. 3. Subsection (a) of section 17b-491 of the general statutes is repealed and the following is substituted in lieu thereof (Effective July 1, 2005):

(a) There shall be a "Connecticut Pharmaceutical Assistance Contract to the Elderly and the Disabled Program" which shall be within the Department of Social Services. The program shall consist of payments by the state to pharmacies for the reasonable cost of prescription drugs dispensed to eligible persons minus a copayment charge. The pharmacy shall collect the copayment charge from the eligible person at the time of each purchase of prescription drugs, and shall not waive, discount or rebate in whole or in part such amount. [Except for a replacement prescription dispensed pursuant to section 17b-492, the] The copayment for each prescription shall be [as follows:] sixteen dollars and twenty-five cents, except that there shall be no copayment for a full benefit dually eligible Medicare Part D beneficiary.

[(1) Sixteen dollars and twenty-five cents if the participant is (A) not married and has an annual income of less than twenty thousand three hundred dollars, or (B) married and has an annual income that, when combined with the participant's spouse, is less than twenty-seven thousand five hundred dollars.

(2) Upon the granting of a federal waiver to expand the program in accordance with section 17b-492, the copayment shall be twenty dollars for a participant who is (A) not married and has an annual income that equals or exceeds twenty thousand three hundred dollars, or (B) married and has an annual income that, when combined with the participant's spouse, equals or exceeds twenty-seven thousand five hundred dollars.]

Sec. 4. Section 17b-492 of the general statutes is repealed and the following is substituted in lieu thereof (Effective July 1, 2005):

(a) Eligibility for participation in the program shall be limited to any resident (1) who is sixty-five years of age or older or who is disabled, (2) whose current annual income at the time of application or redetermination, if unmarried, is less than twenty thousand eight hundred dollars or whose annual income, if married, when combined with that of the resident's spouse is less than twenty-eight thousand one hundred dollars, (3) who is not insured under a policy which provides full or partial coverage for prescription drugs once a deductible is met, except for a Medicare prescription drug discount card endorsed by the Secretary of Health and Human Services in accordance with Public Law 108-173, the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, [once a deductible amount is met] or coverage under Medicare Part D pursuant to said act, and (4) on and after September 15, 1991, who pays an annual thirty-dollar registration fee to the Department of Social Services, except that there shall be no registration fee for a full benefit dually eligible Medicare Part D beneficary. [Effective January 1, 2002, the commissioner shall commence accepting applications from individuals who will become eligible to participate in the program as of April 1, 2002.] On January 1, 1998, and annually thereafter, the commissioner shall increase the income limits established under this subsection over those of the previous fiscal year to reflect the annual inflation adjustment in Social Security income, if any. Each such adjustment shall be determined to the nearest one hundred dollars.

(b) (1) Payment for a prescription under the program shall be made only if no other plan of insurance or assistance is available to an eligible person for such prescription at the time of dispensing, except for benefits received from an endorsed Medicare prescription drug discount card or benefits provided under Medicare Part D. The pharmacy shall make reasonable efforts to ascertain the existence of other insurance or assistance, including the subsidy provided by an endorsed Medicare prescription drug discount card or benefits provided under Medicare Part D.

(2) A Medicare prescription drug discount card beneficiary shall be responsible for the payment of any Medicare prescription drug discount card coinsurance requirements, provided such requirements do not exceed the ConnPACE program copayment requirements. If a Medicare prescription drug discount card beneficiary's coinsurance requirements exceed the ConnPACE copayment requirements, the Department of Social Services shall make payment to the pharmacy to cover costs in excess of the ConnPACE copayment amount. If the cost to such beneficiary exceeds the remaining available Medicare prescription drug discount card subsidy, the beneficiary shall not be responsible for any payment in excess of the amount of the ConnPACE program copayment requirement. In such cases, the Department of Social Services shall make payment to the pharmacy to cover costs in excess of the ConnPACE copayment amount.

(3) A Medicare Part D beneficiary shall be responsible for the payment of Medicare Part D copayments, coinsurance and deductible requirements for Medicare Part D covered prescription drugs, as defined in Public Law 108-173, the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, to the extent such requirements do not exceed the ConnPACE program copayment requirements. The Department of Social Services shall pay Medicare Part D monthly beneficiary premiums on behalf of the beneficiary. If a Medicare Part D beneficiary's out-of-pocket copayment, coinsurance or deductible requirements exceed the ConnPACE copayment requirements, the department shall make payment to the pharmacy to cover costs in excess of the ConnPACE copayment amount. The department shall be responsible for payment of prescription drugs, whenever a ConnPACE recipient presents a prescription for such drug to a pharmacy and payment for such drug is rejected by the Part D plan for any reason, including, but not limited to, the recipient seeking a drug during the gap in standard Medicare Part D coverage. To the extent permitted under said act, payment may be made by the department for a prescription at the lower of the price that would be paid under the ConnPACE program or the negotiated price established by the beneficiary's Medicare Part D plan pursuant to Public Law 108-173, the Medicare Prescription Drug, Improvement, and Modernization Act of 2003.

[(2)] (4) Payment for a replacement prescription under the program shall be made only if the eligible person signs a statement, on such form as the commissioner prescribes and subject to penalty under section 17b-497, that the prescription drug is lost or was stolen or destroyed and the person has made a good faith effort to recover the prescription drug, except that payment for a replacement prescription shall not be made on behalf of a person more than twice in a calendar year. [No copayment shall be required for such replacement prescription.]

(c) Any eligible resident who (1) is insured under a policy, including an endorsed Medicare prescription drug discount card, which provides full or partial coverage for prescription drugs, and (2) expects to exhaust such coverage, may apply to participate in the program prior to the exhaustion of such coverage. Such application shall be valid for the applicable income year. To be included in the program, on or after the date the applicant exhausts such coverage, the applicant or the applicant's designee shall notify the department that such coverage is exhausted and, if required by the department, shall submit evidence of exhaustion of coverage. Not later than ten days after an eligible resident submits such evidence, such resident shall be included in the program. The program shall, except for those beneficiaries with an endorsed Medicare prescription drug discount card, (A) cover prescriptions that are not covered by any other plan of insurance or assistance available to the eligible resident and that meet the requirements of this chapter, and (B) retroactively cover such prescriptions filled after or concurrently with the exhaustion of such coverage. Nothing in this subsection shall be construed to prevent a resident from applying to participate in the program as otherwise permitted by this chapter and regulations adopted pursuant to this chapter.

(d) (1) [As] Until the effective date of the Medicare Part D program pursuant to Public Law 108-173, the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, as a condition of eligibility for participation in the ConnPACE program, a resident with an income at or below one hundred thirty-five per cent of the federal poverty level, who is Medicare Part A or Part B eligible, shall obtain annually an endorsed Medicare prescription drug discount card designated by the Commissioner of Social Services for use in conjunction with the ConnPACE program. The commissioner shall be the authorized representative of such resident for the purpose of enrolling a resident in the transitional assistance program of Public Law 108-173, the Medicare Prescription Drug, Improvement, and Modernization Act of 2003. As the authorized representative for this purpose, the commissioner may sign required forms and enroll such resident in an endorsed Medicare prescription drug discount card on [his or her] the resident's behalf. Such resident shall have the opportunity to select an endorsed Medicare prescription drug discount card designated by the commissioner for use in conjunction with the ConnPACE program, and shall be notified of such opportunity by the commissioner. In the event that such resident does not select an endorsed Medicare prescription drug discount card designated by the commissioner for use in conjunction with the ConnPACE program within a reasonable period of time, as determined by the commissioner, the department shall enroll the resident in an endorsed Medicare prescription drug discount card designated by the commissioner.

(2) [The] Until the effective date of the Medicare Part D program pursuant to Public Law 108-173, the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, the commissioner may require, as a condition of eligibility for participation in the ConnPACE program, that a resident with an income above one hundred thirty-five per cent of the federal poverty level, who is Medicare Part A or Part B eligible, obtain an endorsed Medicare prescription drug discount card designated by the commissioner for use in conjunction with the ConnPACE program if obtaining such discount card is determined by the commissioner to be cost-effective to the state. In such an event, the commissioner may provide payment for any Medicare prescription drug discount card enrollment fees.

(e) On and after the effective date of the Medicare Part D program pursuant to Public Law 108-173, the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, enrollment in the Medicare Part D program, for individuals eligible for such program in accordance with said act, shall be a condition of eligibility for the ConnPACE program. The ConnPACE program shall cover the financial costs of Medicare Part D participation for ConnPACE recipients enrolled in Medicare Part D in accordance with subsection (b) of this section. Effective July 1, 2005, a ConnPACE recipient shall, as a condition of eligibility, provide information regarding the recipient's assets and income, as defined by said act, and that of the recipient's spouse, provided said spouse resides in the same household, as required by the Department of Social Services in order to determine the extent of benefits for which the recipient is eligible under Medicare Part D.

(f) As a condition of eligibility for the ConnPACE program, an applicant or recipient shall appoint the Commissioner of Social Services as such recipient's authorized representative for the purpose of submitting an application to the Social Security Administration to obtain the low income subsidy benefit provided under Public Law 108-173, the Medicare Prescription Drug, Improvement, and Modernization Act of 2003. As the authorized representative for this purpose, the commissioner may sign required forms and enroll the applicant or recipient in a Medicare Part D plan on the applicant or recipient's behalf. The applicant or recipient shall have the opportunity to select a Medicare Part D plan and shall be notified of such opportunity by the commissioner. In the event that such applicant or recipient does not select a Medicare Part D plan within a reasonable period of time, as determined by the commissioner, the department shall enroll the applicant or recipient in a Medicare Part D plan designated by the commissioner in accordance with said act. The applicant or recipient shall appoint the Commissioner of Social Services as such recipient's authorized representative for purpose of claiming and appealing any denial of Medicare Part D benefits and for any other purpose allowed under said act and deemed necessary by the commissioner.

[(e)] (g) The Commissioner of Social Services may adopt regulations, in accordance with the provisions of chapter 54, to implement the provisions of subsection (c) of this section. Such regulations may provide for the electronic transmission of relevant coverage information between a pharmacist and the department or between an insurer and the department in order to expedite applications and notice. The commissioner may implement the policies and procedures necessary to carry out the provisions of this section while in the process of adopting such policies and procedures in regulation form, provided notice of intent to adopt the regulations is published not later than twenty days after the date of implementation. Such policies and procedures shall be valid until the time the final regulations are adopted.

Sec. 5. Section 17b-280 of the general statutes is repealed and the following is substituted in lieu thereof (Effective July 1, 2005):

(a) The state shall reimburse for all legend drugs provided under the Medicaid, state-administered general assistance, ConnPACE and Connecticut AIDS drug assistance programs at the rate established by the [Health Care Finance Administration] Centers for Medicare and Medicaid Services as the federal [acquisition cost] upper limit, or, if no such rate is established, the commissioner shall establish and periodically revise the estimated acquisition cost in accordance with federal regulations. The commissioner shall also establish a professional fee of three dollars and fifteen cents for each prescription to be paid to licensed pharmacies for dispensing drugs to Medicaid, ConnPACE and Connecticut AIDS drug assistance recipients in accordance with federal regulations, [; and on and after September 4, 1991, payment] except that no such fee shall be paid for a prescription drug dispensed to a ConnPACE or Medicaid recipient who is a Medicare Part D beneficiary when the prescription drug is a Medicare Part D drug, as defined in Public Law 108-173, the Medicare Prescription Drug, Improvement, and Modernization Act of 2003. Payment for legend and nonlegend drugs provided to Medicaid recipients shall be based upon the actual package size dispensed. Effective October 1, 1991, reimbursement for over-the-counter drugs for such recipients shall be limited to those over-the-counter drugs and products published in the Connecticut Formulary, or the cross reference list, issued by the commissioner. The cost of all over-the-counter drugs and products provided to residents of nursing facilities, chronic disease hospitals, and intermediate care facilities for the mentally retarded shall be included in the facilities' per diem rate.

(b) The Department of Social Services may provide an enhanced dispensing fee to a pharmacy enrolled in the federal Office of Pharmacy Affairs Section 340B drug discount program established pursuant to 42 USC 256b or a pharmacy under contract to provide services under said program.

Sec. 6. Section 17b-264 of the general statutes is repealed and the following is substituted in lieu thereof (Effective July 1, 2005):

All of the provisions of sections 17b-22, 17b-75 to 17b-77, inclusive, 17b-79 to 17b-103, inclusive, and 17b-600 to 17b-604, inclusive, are extended to the medical assistance program except such provisions as are inconsistent with federal law and regulations governing Title XIX of the Social Security Amendments of 1965 and sections 17b-260 to 17b-262, inclusive, 17b-264 to 17b-285, inclusive, and 17b-357 to [17b-362] 17b-361, inclusive.

Sec. 7. Subsection (a) of section 17b-266 of the general statutes is repealed and the following is substituted in lieu thereof (Effective July 1, 2005):

(a) The Commissioner of Social Services may, when [he] the commissioner finds it to be in the public interest, fund part or all of the cost of benefits to any recipient under sections 17b-260 to 17b-262, inclusive, 17b-264 to 17b-285, inclusive, 17b-357 to [17b-362] 17b-361, inclusive, 17b-289 to 17b-303, inclusive, and section 16 of public act 97-1 of the October 29 special session*, through the purchase of insurance from any organization authorized to do a health insurance business in this state or from any organization specified in subsection (b) of this section.

Sec. 8. Subsection (a) of section 17b-267 of the general statutes is repealed and the following is substituted in lieu thereof (Effective July 1, 2005):

(a) If any group or association of providers of medical assistance services wishes to have payments as provided for under sections 17b-260 to 17b-262, inclusive, 17b-264 to 17b-285, inclusive, and 17b-357 to [17b-362] 17b-361, inclusive, to such providers made through a national, state or other public or private agency or organization and nominates such agency or organization for this purpose, the Commissioner of Social Services is authorized to enter into an agreement with such agency or organization providing for the determination by such agency or organization, subject to such review by the Commissioner of Social Services as may be provided for by the agreement, of the payments required to be made to such providers at the rates set by the hospital cost commission, and for the making of such payments by such agency or organization to such providers. Such agreement may also include provision for the agency or organization to do all or any part of the following: With respect to the providers of services which are to receive payments through it, (1) to serve as a center for, and to communicate to providers, any information or instructions furnished to it by the Commissioner of Social Services, and to serve as a channel of communication from providers to the Commissioner of Social Services; (2) to make such audits of the records of providers as may be necessary to insure that proper payments are made under this section; and (3) to perform such other functions as are necessary to carry out the provisions of sections 17b-267 to 17b-271, inclusive.

Sec. 9. Section 17b-272 of the general statutes is repealed and the following is substituted in lieu thereof (Effective July 1, 2005):

Effective July 1, 1998, the Commissioner of Social Services shall permit patients residing in nursing homes, chronic disease hospitals and state humane institutions who are medical assistance recipients under sections 17b-260 to 17b-262, inclusive, 17b-264 to 17b-285, inclusive, and 17b-357 to [17b-362] 17b-361, inclusive, to have a monthly personal fund allowance of fifty dollars. Effective July 1, 1999, the commissioner shall increase such allowance annually to reflect the annual inflation adjustment in Social Security income, if any.

Sec. 10. Section 53a-290 of the general statutes is repealed and the following is substituted in lieu thereof (Effective July 1, 2005):

A person commits vendor fraud when, with intent to defraud and acting on such person's own behalf or on behalf of an entity, such person provides goods or services to a beneficiary under sections 17b-22, 17b-75 to 17b-77, inclusive, 17b-79 to 17b-103, inclusive, 17b-180a, 17b-183, 17b-260 to 17b-262, inclusive, 17b-264 to 17b-285, inclusive, 17b-357 to [17b-362] 17b-361, inclusive, 17b-600 to 17b-604, inclusive, 17b-749, 17b-807 and 17b-808 or provides services to a recipient under Title XIX of the Social Security Act, as amended, and, (1) presents for payment any false claim for goods or services performed; (2) accepts payment for goods or services performed, which exceeds either the amounts due for goods or services performed, or the amounts authorized by law for the cost of such goods or services; (3) solicits to perform services for or sell goods to any such beneficiary, knowing that such beneficiary is not in need of such goods or services; (4) sells goods to or performs services for any such beneficiary without prior authorization by the Department of Social Services, when prior authorization is required by said department for the buying of such goods or the performance of any service; or (5) accepts from any person or source other than the state an additional compensation in excess of the amount authorized by law.

Sec. 11. Sections 17b-274b and 17b-362 of the general statutes are repealed. (Effective July 1, 2005)

This act shall take effect as follows and shall amend the following sections:

Section 1

July 1, 2005

New section

Sec. 2

July 1, 2005

17b-490

Sec. 3

July 1, 2005

17b-491(a)

Sec. 4

July 1, 2005

17b-492

Sec. 5

July 1, 2005

17b-280

Sec. 6

July 1, 2005

17b-264

Sec. 7

July 1, 2005

17b-266(a)

Sec. 8

July 1, 2005

17b-267(a)

Sec. 9

July 1, 2005

17b-272

Sec. 10

July 1, 2005

53a-290

Sec. 11

July 1, 2005

17b-274b and 17b-362 repealed

Statement of Purpose:

To ensure that ConnPace and full benefit dually eligible Medicare Part D beneficiaries continue to receive the same level of prescription drug coverage and benefits when the Medicare Part D program is fully implemented.

[Proposed deletions are enclosed in brackets. Proposed additions are indicated by underline, except that when the entire text of a bill or resolution or a section of a bill or resolution is new, it is not underlined.]