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Restoring Patient Protections


In 2011, New York changed the process by which 4 million Medicaid recipients obtain prescription drug coverage. The pharmacy benefit was “carved in” to Manage Care instead of a fee for service program. This change resulted in patients losing many protections and has led to confusion, lack of uniformity in coverage and, in some cases, denial of critical medications.

Patient advocates, health care providers and many members of the NYS Legislature are fighting to restore those patient protections. Those protections included a comprehensive drug formulary, standardization of drug benefits and maintaining the prescriber’s authority to decide what medicine a patient needs, frequently referred to as “prescriber prevails.”

In 2012, the advocacy effort resulted in restoration of “prescriber prevails” for atypical antipsychotics in the 2012-2013 Executive Budget (effective January 1, 2013). A standard prior authorization bill was also passed and signed by the governor. This bill (effective January 1, 2013) requires a uniform prior authorization form in Medicaid that will enhance patient access, relieve overburdened health care providers and allow providers more time to treat patients.

The goal for 2013 is restore “prescriber prevails” for all drug classes so that all patients will have equal access to medicines they need and and that their doctor prescribes.

UPDATE 4/1/13: The prescriber prevails provision was restored for all drug classes to the NY Medicaid Budget. Congrats to all the patients, advocates and legislative members who championed this cause.

UPDATE 2/4/13: Senator David Carlucci and Assembymember Aileen Gunther, Chairs of their respective Mental Health Committees, were joined by advocates, physicians and patients at a press event to call on Gov. Cuomo to restore prescriber prevails to the NY Medicaid Budget. The group detailed how this policy change has led and will continue to lead to disruptions in medication access, health complications for patients and increased health care costs.

Here is the press release for more info.

UPDATE 1/23/13: Gov. Cuomo’s budget, unveiled Jan. 22, 2013, included a repeal of the “prescriber prevails” provision for atypical antipsychotics. Restoring this patient protection was a hard-fought victory achieved last year by patient advocacy groups. As such, patient groups are not allowing the administration to repeal the measure just one year later without a fight.

Mental Health Association in NYS, Gay Men’s Health Crisis, NYS Osteopathic Medical Society, and the Association of Hispanic Mental Health Professionals all released statements opposing the budget measure.

Click here for the statements.

UPDATE 1/18/13: Gay Men’s Health Crisis (GMHC) issued its recommendations to restore patient protections for Medicaid prescription drug coverage in the 2013-2014 Executive Budget. Here is the organization’s memo: GMHC Recommendations_Patient Protections

2012 “Patient Protections” Recap

A press conference was held on Feb. 29, 2012. Here is a video from the event and here  is the press release.

Advocates also released a statement on March 7, 2012 that acknowledged the correct decision made by Gov. Cuomo to allow Medicaid recipients access to all forms of contraception. But they also urge the Governor to address the lack of patient protections for other vulnerable populations.

Please see below for updates on the fight for patient protections and prescriber prevails in NY (in chronological order).

UPDATE, 3/30/12: The final budget allows for providers to have final say when prescribing atypical antipsychotics to Medicaid recipients. This is an important step but more needs to be accomplished to properly address access to care issues experienced by Medicaid patients. Below is the full statement by several patient advocacy groups.

Statement on the Lack of a Universal Prescriber Prevails Provision in the Final New York State Budget

Why Patient Protections are Important (and Affordable)

Letter to NYS Legislative Leaders Signed by Numerous Advocacy Groups

Letter to Gov. Cuomo From a Group of Minority Legislative Members and Minority Advocacy Groups

UPDATE, 6/11/12: The tremendous effort that advocacy groups put forth during the budget process to restore prescription drug patient protections in Medicaid is paying off. The final budget did include the restoration of prescriber prevails for atypical antipsychotics – a move which recognized that access was impaired for some Medicaid recipients. The Assembly and Senate are continuing the drive, through newly introduced bills, toward ensuring that prescribers will have the final say on prescription drug regimens across all drug classes.

Both houses have also introduced new legislation to create a standard prior authorization process across health plans. A standardized form is intended to relieve overburdened health care providers of navigating through 21 different Medicaid prior authorization processes. A uniform process will also enhance patient access by removing a barrier to prescribing practices.

There are differences between the Assembly and Senate approach to both issues. The Senate simply calls for a Department of Health-approved uniform prior authorization form and allows for prescriber prevails across all drug classes in Medicaid. The Assembly’s standardized prior authorization bill applies to Medicaid and commercial health plans, and requires input from the Superintendent of Financial Services. While all plans must accept the standard form, prescriber use is optional unless mandated by an insurer. The Assembly also sets time frames for drug approval. Failure to do so results in automatic approval.

The Assembly’s prescriber prevails proposal restores prescriber prevails to all drug classes and restores the prior approval carve-out for atypical antipsychotics, anti-retroviral and anti-rejection drugs and for other drug classes used to treat mental illness and HIV/AIDS, upon approval of the Department of Health. Prior authorization requests must be addressed within 24 hours with limited exception. Additions to the Preferred Drug List must consider patient safety, efficacy and outcomes. Cost effectiveness can be a consideration, albeit secondary. Lastly, the Assembly proposal requires the development of performance standards to help ensure timely responses to patients.

Both the Assembly and Senate proposals are effective approaches to resolving prescription drug access problems for Medicaid recipients. Although outside of the conventional budget process, it is possible that with strong advocacy, these bills can become end of session priorities for both houses. Ultimately, there will have to be agreement on a unified approach in order to send a bill to the Governor. Agreement will require flexibility from advocates and negotiators in crafting a final product.

UPDATE, 6/14/12: Both the prescriber prevails and standardized authorization bills have been amended to “same-as” bills. This is positive development, as the Senate and Assembly have come to an agreement on bill language.

To recap, A.10249 (P. Rivera) / S.7632 (Hannon) will restore prescriber prevails in Medicaid for all drug classes so that health care providers will have final say when it comes to their patient’s medication regimens.

A.10248 (P.Rivera) / S.7384 requires a uniform prior authorization form in Medicaid that will enhance patient access, relieve overburdened health care providers and allow providers more time to treat patients.

UPDATE, 6/21/12: The standardized prior authorization bill passed the both the Assembly and Senate. Now it goes to the Governor for his signature. Read more about the next steps for this bill and for an update on the prescriber prevails bill.

UPDATE, 10/5/12: The standard prior authorization bill was signed into law by Governor Cuomo on Oct. 4, 2012. This bill (A.10248 / S.7384) requires a uniform prior authorization form in Medicaid that will enhance patient access, relieve overburdened health care providers, and allow providers more time to treat patients.

UPDATE, 12/14/12: The Department of Health has recently released a draft prior authorization form for Medicaid Managed Care Plans. In developing the form, the Department of Health (DOH) looked at their prior authorizations process under fee for service, Medicare Part D, managed care plan processes and other states. The law authorized the development of more than one form; however, the DOH will determine in the future if another form is necessary. This draft is being vetted by the health plans and the MRT Mental Health Workgroup. Their input could help determine if additional forms are necessary. Managed Care Plans will be required to make this form available both in paper and electronic form.  The DOH expects this to be ready for use by January 1, 2013.

Medicaid Redesign Team (MRT)

Update, 11/21/13

Medicaid Pharmacy Prior Authorization Programs Update: Effective December 5, 2013, the fee-for-service pharmacy program will implement new parameters, including step therapy and frequency/quantity/duration requirements. These changes are the result of recommendations made by the Drug Utilization Review Board (DURB) at the September 12, 2013 DURB meeting. Click here for the new parameters.

Update, 11/26/12

Below is the DRAFT plan for the 2012 NYS Medicaid Managed Care Program’s State Quality Strategy, as required by Federal Law. It’s now available for public comment. Comments may be submitted to qi@health.state.ny.us and are due by Dec. 28, 2012.

Quality Strategy for the New York State Medicaid Managed Care Program 2012

Update, 9/25/12

One of the most important Medicaid Redesign Team (MRT) initiatives currently underway is the transition of as many patient populations and services as possible to managed care. This transition, designated as Care Management for All, began in state fiscal year 2011/2012 and will take several years to implement.

Summary Explanation of the MRT Care Management for All Transition Plan, 09/25/12

MRT News August 2012 First issue of this quarterly publication that highlights MRT initiatives that are currently being implemented.

Update, 8/7/12: On August 6, 2012, Gov. Cuomo submitted to the Center for Medicaid Services the much-anticipated MRT Medicaid waiver amendment that, if approved, will allow the state to reinvest Medicaid savings into new programs that are designed to reap more savings in the years to come.

The waiver amendment seeks to invest $10 billion over five years on 13 new programs, includingprimary care expansion, public health initiatives, workforce retraining, hospital restructuring, supportive housing, long term care transformation and capital funds to support safety net hospitals.

For more information on the MRT waiver, go here.
Overview of the Medicaid Redesign Team
The Medicaid Redesign Team (MRT) was created by Governor Cuomo in January 2011. The purpose of the MRT is to save money and improve quality outcomes in the Medicaid program. The MRT consists of up to 25 voting members from the health care provider, business, legislative and health insurance sectors. It also includes state officers and state employees. An MRT member list can be found here.

The 2011-12 state budget included 73 recommendations from Phase I of the MRT for savings of $2.2 billion in year one and $3.3 billion in year two. Among the enacted recommendations: bundling the Medicaid pharmacy benefit into managed care (effective October 1, 2011), elimination of a pharmacy prescriber prevails provision (effective May 1, 2011), allow prior authorization for exempted drug classes (effective October 1, 2011), expansion of populations entering Medicaid managed care over a three-year period (beginning July 1, 2011), establishment of Behavioral Health Organizations (operational before January 2012), establishment of Medicaid Health Homes (operational November 2011), global cap on Medicaid expenditures (effective April 1, 2011) and across the board Medicaid reductions (effective April 1, 2011).

Phase II began work over the summer of 2011. MRT ‘workgroups’ have been established and are designed to bring more stakeholders into the process and to make recommendations to the full MRT by December for consideration in the 2012-13 state budget. Workgroups currently meeting: Basic Benefit Review Work Group, Behavioral Health Reform Work Group, Health Disparities Work Group, Health Systems Redesign: Brooklyn Work Group, Managed Long Term Care  Implementation and Waiver Redesign, Payment Reform and Quality Measure Work Group, Program Streamlining and State/Local Responsibilities. Three additional workgroups will begin meeting shortly: Supportive Housing, Workforce Flexibility and Medical Malpractice. Check our Community Advocacy Calendar for dates and locations of these meetings.

Detailed Summary of MRT Work Group Meeting: Behavioral Health Reform, 09/12/11

Detailed Summary of MRT Work Group Meeting: Basic Benefit Review, 09/14/11

Materials disseminated at MRT Work Group Meeting: Basic Benefit Review

Detailed Summary of MRT Work Group Meeting: Managed Long Term Care Implementation and Waiver Redesign, 09/19/11

Detailed Summary of MRT Long Term Care Implementation and Waiver Redesign Work Group Meeting, 09/28/11

Detailed Summary of the Full Meeting of the MRT, 10/05/11

Detailed Summary of MRT Basic Benefit Review Work Group Meeting, 10/19/11

Detailed Summary of MRT Workforce Flexibility/Change of Scope of Practice Work Group Meeting, 10/27/11

Detailed Summary of MRT Managed Long Term Care Implementation and Waiver Redesign Work Group Meeting, 10/27/11

Detailed Summary of MRT Full Meeting, 11/01/11

Work Group Recommendations at MRT Full Meeting, 11/01/11

Detailed Summary of Final Meeting of the Full Medicaid Redesign Team, 12/13/11 (linked and below)

The final meeting of the full Medicaid Redesign Team (MRT) was held Dec. 13 in Albany.  In addition to a webcast, other meeting materials can be found here.  The general purpose of today’s meeting was to accept the reports from the remaining work groups and outline the process for the transmittal of the final MRT recommendations to Governor Cuomo.

The meeting began with an update from State Medicaid Director Jason Helgerson on the status of Medicaid spending in relation to the global spending cap.  Helgerson reported that Medicaid spending through the end of October squeaked in under the projected spending amount.  Estimated spending had been at $9,265,558 but the actual spending was at $9,140,844-a difference of $124,714. Although spending was less than anticipated, Helgerson noted that the Department continues to closely watch the Medicaid enrollment numbers. Since April there has been a 2 percent increase in Medicaid enrollment and a 2.7 percent increase in Medicaid Managed Care enrollment. While the Department is monitoring the enrollment numbers Helgerson did note that the antiquated eligibility system in New York could be skewing the enrollment numbers. The formal report on Medicaid spending should be available on the Department’s website today.

The focus of the meeting then shifted to an overview of the process by which the MRT would share its recommendations with Governor Cuomo. It was reported that Department of Health staff have prepared a report that will be shared with the MRT members for review and feedback. This report will include a summary of Phase 1 MRT reforms and the approved recommendations of the MRT work groups. This report will be sent to the MRT membership on December 14th with the understanding that any feedback from MRT members must be received by December 20th. The final report will be sent to Governor Cuomo on December 31st.

Prior to the sharing of the work group reports there was a brief discussion among MRT members as to whether the workgroups would continue meeting after the report was sent to the Governor. There is no formal process in place by which the work groups will continue to meet. All parties agreed that this issue warrants further discussion.

The presentations of the four work groups were largely uneventful. Co-chairs for each work group gave presentations on their respective work group’s activities and final recommendations. The Basic Benefit Review work group presented first, followed by the Workforce Flexibility and Scope of Practice work group, the Payment Reform and Quality Measurement work group and the Affordable Housing work group. For the most part the recommendations of the work groups were accepted by MRT members with little controversy. However, there was a lively discussion regarding recommendations contained in the Basic Benefit Review work group’s presentation. The work group had proposed creating an evidence based system to review whether a benefit should be covered under Medicaid. Both Assembly member Gottfried and Senator Hannon expressed reservations about this concept. Ultimately it was agreed that the recommendation should reflect that any meetings regarding changing Medicaid benefits be open to the public and that the Legislature’s role in changing Medicaid benefits must be preserved.

Another notable exception to the approval of recommendations was Assemblyman Gottfried’s decision to abstain from voting on the Workforce Flexibility and Scope of Practice work group recommendations. Gottfried explained that the Assembly’s chair of the Higher Education Committee Deborah Glick had reservations about some of the proposals and that in deference to those concerns he would not be voting for the package. Additionally, a large number of people from the labor union DC 37 were in attendance to protest some of the MRT Phase I proposals relating to rolling certain benefits and populations into Medicaid Managed Care. In a departure from the MRT’s normal practice, Co-Chair Michael Dowling gave the group’s representatives a five-minute time slot to speak to the larger group.

Before the close of the meeting, MRT member Stephen Berger made a motion that a recommendation in support of increased staffing for the Department of Health be included in the report to Governor Cuomo. The group agreed that increased staffing was critical to the success of many of the MRT initiatives.

Centers for Medicare and Medicaid Services (CMS)

The Centers for Medicare and Medicaid Services (CMS) at the federal level is working with states to develop demonstration projects to provide integrated healthcare for dual eligibles (those that are eligible for both Medicaid and Medicare). Dual eligibles are some of the most costly patients for the healthcare system, but they are also often the most vulnerable due to financial status, significant long-term disease, comorbidities, and/or being differently-abled physically and/or mentally.

Learn more about New York’s demonstration project and how you can help protect New York’s dual eligible patients.

Partnership for Prescription Assistance (PPA)

With an 8 percent unemployment rate and more than 14 percent of New Yorkers remaining uninsured, according to the latest Gallup poll numbers, there are many New Yorkers who need help. The Partnership for Prescription Assistance matches uninsured and financially struggling people to patient assistance programs that provide free or nearly free medicine, and this free program has matched more than 230,000 New Yorkers with programs that may help.

Our mission is to increase awareness of patient assistance programs and boost enrollment of those who are eligible. We offer a single point of access to more than 475 public and private programs, including nearly 200 offered by pharmaceutical companies. We have already helped millions of Americans who applied to patient assistance programs get free or reduced-cost prescription medicines.

There are other companies that offer to connect consumers to these same programs for a fee – some of which use our name without our permission. The Partnership for Prescription Assistance will help you find the program that’s right for you, free of charge. Remember, you will never be asked for money by a PPA Call Center representative, or on our web site.

PPA Bus Tours

Millions of Americans have been helped by public and private patient assistance programs, but millions more could benefit. That’s why the Partnership for Prescription Assistance launched the Help Is Here Express bus tour. Our rolling information centers are equipped with computer terminals and mobile telephones so patients can find out if they may be eligible for free or reduced-cost medicines while onboard.

PPA Video Overview

PPA Fact Sheet

PPA Website

Prescription Drugs

New York State Public Health Law requires the state to collect and publish the prices of the most commonly prescribed drugs at all participating Medicaid pharmacies. This list makes it easy for patients to compare prices before filling their prescriptions.

New York State Prescription Drug Price List

Disease Prevention

America’s research-based pharmaceutical companies are working actively in partnership with the U.S. Government and world health officials to make sure that patients have the vaccines and antiviral treatments they need to help prevent and treat the flu and avian flu.

Operational Framework for Partnering with Pharmacies for Administration of 2009 H1N1 Vaccine

CDC info on H1N1

World Health Organization recommendations for schools to reduce the impact of H1N1.

Upcoming Events
  • October 8, 2015 – Senator Hannon's Senior Health Expo
    9:00 am, Long Island
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