You asked (1) for the ConnPACE eligibility criteria, (2) what the program pays for, (3) how much the state spends annually, and (4) how many people are enrolled. You also asked about the ConnMAP program, including whether it is still operational.

SUMMARY

The ConnPACE program subsidizes the pharmaceutical costs of low-income elderly (aged 65 and over) and disabled individuals whose prescriptions are not otherwise covered under an insurance plan. To qualify, income cannot exceed $14,500, if single, and $17,500 for married couples. (These figures rise by $200 on January 1, 2000.) Participants pay an annual $25 fee and make $12 co-payments for each prescription. The program pays for prescription drugs, insulin, and insulin syringes and needles. Certain items, such as diet pills and multivitamins are not covered. As of September 30, 1999, 27,995 were enrolled (28,967 individuals were actively enrolled during the first quarter of the FY 1999-2000, but events such as Medicaid eligibility, client moves, and deaths reduced this number; of these, approximately 12% were people with disabilities between the ages of 18 and 64).

The legislature appropriated $26.6 million for ConnPACE in FY 1999-2000. The Office of Fiscal Analysis estimates an $8.8 million deficiency in the program, which reflects continued growth in the number of disabled enrollees, strong pharmaceutical inflation, and recognition that a $2.1 million budgeted savings will not be realized. Nearly $8.9 million was spent on these prescriptions during the first quarter of FY 1999-2000.

The ConnMAP law prohibits Medicare Part B providers (physicians and other service providers) from billing enrollees for the balance of charges beyond the Medicare "reasonable and necessary" rate for goods and services (a practice know as "balance-billing"). To be eligible, an individual's annual income may not exceed $23,925, if single, and $28,875 if married. This program currently enrolls 27,638 people. The Department of Social Services (DSS), which administers both it and ConnPACE, does ongoing outreach, including the distribution of brochures and applications at various outlets where seniors get information.

CONNPACE

The ConnPACE program has served the state's elderly since 1985 and the disabled since 1987. (To qualify as disabled an individual must be at least 18 years old and be receiving Social Security Disability Income (Title II) or Supplemental Security Income (SSI) (Title XVI)). The program's income limits are net amounts, which are derived by taking federal adjusted gross income (AGI), adding any other income not included in the AGI, and subtracting Medicare Part B premiums.

While most prescriptions are covered, certain drugs are not. These include diet pills, smoking cessation gum, contraceptives, multivitamin combinations, cough preparations, antihistamines, most cosmetics, experimental drugs, and drugs that the Food and Drug Administration has determined not to be effective. Pharmacists must substitute generic brands for name brand ones unless the prescribing physician indicates that only a name brand may be used. Pharmacists may only dispense the greater of a 30-day supply or 120 units. The average prescription cost during the last quarter (July 1 through September 30, 1999) was $59.33. This represents a 40% increase since the same quarter in FY 1996-97. The average cost for a generic drug was $26.69. Almost the same number of prescriptions costing over $100 (15.19%) were prescribed as those costing less than $10 (15.29%).

The legislature has amended the program from time to time, most recently with a change to ensure that people whose limited insurance coverage runs out get ConnPACE benefits in a timely fashion (PA 98-194). In 1997 the legislature re-activated an indexing provision in the law which requires, rather than allows, the DSS commissioner to adjust the income limits to reflect cost-of-living adjustments in the Social Security program.

CONNMAP

Under ConnMAP, any provider accepting Medicare patients may not balance bill program enrollees beyond the 20% co-payment for the service. (Patients are also responsible for the Part B premiums and deductibles.) The income limits for the ConnMAP program are tied to those for the ConnPACE program. The current maximum is 165% of the ConnPACE limits. ConnPACE recipients can use their ConnPACE cards in lieu of a ConnMAP card, and providers must accept both. Applicants must have resided in the state for at least 183 days before applying and be enrolled in Medicare Part B.

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