Sec. KKK-1. 22 MRSA §254, as amended by PL 1997, c. 643, Pt. RR, §§1 and 2, is further amended to read:
§254. Elderly low-cost drug program
The Department of Human Services may conduct a program to provide low-cost prescription and nonprescription drugs, medication and medical supplies to disadvantaged, elderly and disabled individuals. In any year in which this program is conducted, it must include any prescription drugs used for the treatment of chronic obstructive lung disease.
In any year in which this program is conducted, it must include antiarthritic drugs.
In any year in which this program is conducted, it must include anticoagulant drugs.
The commissioner shall provide for sufficient personnel to ensure efficient administration of the program. The extent and the magnitude of the program shall must be determined by the commissioner on the basis of the calculated need of the recipient population and the available funds. The department may not spend more on this program than is available through appropriations from the General Fund, dedicated revenue, federal or other grants and other established and committed funding sources. The commissioner may accept, for the purposes of carrying out this program, federal funds appropriated under any federal law relating to the furnishing of free or low-cost drugs to disadvantaged, elderly and disabled individuals and may take such action as is necessary for the purposes of carrying out that federal law and may accept from any other agency of government, individual, group or corporation such funds as may be available to carry out this chapter.
The commissioner may adopt rules relating to the conduct of this program. These rules shall must be promulgated adopted in accordance with the Maine Administrative Procedure Act, Title 5, chapter 375, and shall must be related to the following aspects of this program:
1. Prescription and nonprescription drugs. The kinds of prescription and nonprescription drugs, medications and medical supplies which that may be made available through the operation of this program;. Drugs and medications must be provided for the conditions and illnesses provided in this subsection.
A. The basic component of the program must provide drugs and medications for cardiac conditions and high blood pressure, diabetes, arthritis, anticoagulation, hyperlipidemia, osteoporosis, chronic obstructive pulmonary disease and asthma, incontinence, thyroid diseases, glaucoma, parkinson's disease, multiple sclerosis and amyotrophic lateral sclerosis.
B. Beginning October 1, 1999, in the supplemental component of the program, drugs and medications must include all prescription drugs and medications provided under the Medicaid program under this Title with the exception of drugs and medications provided by the basic component of the program under paragraph A;
2. Income eligibility. Eligibility status Income eligibility of individuals shall must be determined by the State Tax Assessor pursuant to Title 36, chapter 905 this subsection and by reference to the federal nonfarm income official poverty level, as defined by the federal Office of Management and Budget and revised annually in accordance with the United States Omnibus Budget and Reconciliation Act of 1981, Section 673, Subsection 2. If the household income, as defined in subsection 9, is less than 185% of the federal poverty line applicable to the household, the individual is eligible for the basic and the supplemental program. Individuals are also eligible for the basic program and the supplemental program if the household spends at least 40% of its income on unreimbursed direct medical expenses for prescription drugs and medications and the household income is not more than 25% higher than the levels specified in this subsection. For the purposes of this subsection, the cost of drugs provided to a household under this section is considered a cost incurred by the household for eligibility determination purposes;
3. Specifications for administration of program. Specifications for the administration and management of the program, which may include, but not be limited to, program objectives, accounting and handling practices, supervisory authority and evaluation methodology;
4. Method of prescribing or ordering drugs. The method of prescribing or ordering these drugs, which may include, but is not limited to, the use of standard or larger prescription refill sizes so as to minimize operational costs and to maximize economy. Unless the prescribing physician indicates otherwise, the use of generic or chemically equivalent drugs is required, provided that these drugs are of the same quality and have the same mode of delivery as is provided to the general public, consistent with good pharmaceutical practice. Each prescription filled must be for a supply of 90 days unless the prescribing physician or the recipient requests otherwise;
4-A. Payment for drugs provided. The commissioner may establish the amount of payment to be made by recipients toward the cost of prescription or nonprescription drugs, medication and medical supplies furnished under this program provided that, for persons at or below 185% of the federal poverty line, the total cost for any covered purchase of a prescription or nonprescription drug or medication provided under the basic component of the program does not exceed 20% of the price allowed for that prescription under program rules or $2, whichever is greater. If a recipient is prescribed a drug in a quantity specifically intended by the provider or pharmacist, for the recipient's health and welfare, to last less than one month, only one payment for that drug for that month is required For the supplemental component of the program, the total cost paid by the program for any covered purchase of a prescription drug or medication may not exceed $2. For the supplemental component of the program, the total cost paid by the individual for any covered purchase of a prescription drug or medication may not exceed the cost of the program for that drug or medication minus the $2 paid by the program;
5. Other rules. Such other rules as may be necessary to efficiently and effectively manage and operate a program within the intent of this section.;
7. Wholesale price. "Wholesale price" means the average price paid by a wholesaler to a pharmaceutical manufacturer for a product distributed for retail sale. "Wholesale price" includes a deduction for any customary prompt payment discounts.;
8. Drug rebate program. Effective May 1, 1992, payment must be denied for drugs from manufacturers that do not enter into a rebate agreement with the department for prescription drugs included in the list of approved drugs under this program. Each agreement must provide that the pharmaceutical manufacturer make rebate payments for both the basic and supplemental components of the program to the department according to the following schedule.
A. For the period beginning May 1, 1992 and ending September 30, 1992, the rebate percentage is equal to 11% of the manufacturer's wholesale price for the total number of dosage units of each form and strength of a prescription drug that the department reports as reimbursed to providers of prescription drugs, provided payments are not due until 30 days following the manufacturer's receipt of utilization data supplied by the department, including the number of dosage units reimbursed to providers of prescription drugs during the period for which payment is due.
B. For the quarters beginning October 1, 1992, the rebate percentage is equal to the percentage recommended by the federal Health Care Financing Administration of the manufacturer's wholesale price for the total number of dosage units of each form and strength of a prescription drug that the department reports as reimbursed to providers of prescription drugs, provided payments are not due until 30 days following the manufacturer's receipt of utilization data supplied by the department, including the number of dosage units reimbursed to providers of prescription drugs during the period for which payments are due.
C. Beginning October 1, 1998, the department shall seek to achieve an aggregate rebate amount from all rebate agreements that is 6 percentage points higher than that required by paragraph B of this subsection, provided such rebates result in a net increase in the rebate revenue available to the elderly low-cost drug program. In the event the department is not able to achieve the rebate amount required by this paragraph without compromising the best interest of recipients of the elderly low-cost drug program, it shall report to the joint standing committee of the Legislature having jurisdiction over health and human services matters and the joint standing committee of the Legislature having jurisdiction over appropriations and financial affairs in the First Regular Session of the 119th Legislature.
Upon receipt of data from the department, the pharmaceutical manufacturer shall calculate the quarterly payment. If a discrepancy is discovered, the department may, at its expense, hire a mutually agreed-upon independent auditor to verify the pharmaceutical manufacturer's calculation. If a discrepancy is still found, the pharmaceutical manufacturer shall justify its calculation or make payment to the department for any additional amount due. The pharmaceutical manufacturer may, at its expense, hire a mutually agreed-upon independent auditor to verify the accuracy of the utilization data provided by the department. If a discrepancy is discovered, the department shall justify its data or refund any excess payment to the pharmaceutical manufacturer.
If the dispute over the rebate amount is not resolved, a request for a hearing with supporting documentation must be submitted to the Administrative Hearings Unit. Failure to resolve the dispute may be cause for terminating the drug rebate agreement and denying payment to the pharmaceutical manufacturer for any drugs.
All prescription drugs of a pharmaceutical manufacturer who enters into an agreement pursuant to this subsection that appear on the approved list of drugs must be immediately available and the cost of the drugs must be reimbursed and is not subject to any restrictions or prior authorization requirements. Any prescription drug of a manufacturer that does not enter into an agreement is not reimbursable unless the department determines the prescription drug is essential. The department shall seek a manufacturer's rebate for pharmaceuticals used in the Maine Health Program.;
9. Household income. "Household income," for the purposes of this section, means all income, as defined in Title 36, section 6201, subsection 9, received by all persons of a household in a calendar year while members of the household; and
10. Eligible individuals. To be eligible for the program, an individual must be:
A. At least 62 years of age; or
B. Nineteen years of age or older and determined to be disabled by the standards of the federal social security program.
Sec. KKK-2. 22 MRSA §3174-G, sub-§1-A, as enacted by PL 1997, c. 643, Pt. RR, §4, is repealed and the following enacted in its place:
1-A. Elderly prescription drug program. The department shall apply to the federal Health Care Financing Administration for a waiver authorizing the department to provide Medicaid prescription drug benefits to qualified persons who are 62 years of age or older or who are 19 years of age or older and determined by the department to be disabled under the standards of the federal social security program and who have household income up to and including 185% of the nonfarm income official poverty line. If sufficient funds are not allocated or appropriated to provide prescription drug coverage under this subsection to eligible persons with household income up to and including 185% of the nonfarm income official poverty line, the department shall provide coverage under this section up to the maximum income eligibility limit that can be achieved within the funds appropriated and allocated. The waiver must include the full range of prescription drugs provided under the current Medicaid program. It may not include an asset limit. Copayments for participants must be comparable to copayments in the current Medicaid program. Coverage under this subsection must commence July 1, 2000 or as soon thereafter or possible.
Sec. KKK-3. 22 MRSA §3174-G, sub-§1-B is enacted to read:
1-B. Funding. State funds necessary to implement subsection 1-A must include state funds appropriated to the elderly low-cost drug program operated pursuant to section 254, including rebates received in that program from pharmaceutical manufacturers, that are no longer needed in that program as a result of the Medicaid waiver obtained pursuant to subsection 1-A; and, effective in fiscal year 2000-01, no less than $5,000,000 received from the tobacco settlement in State of Maine, v. Philip Morris, et al., Kennebec County Superior Court, Docket No. CV-97-134.
Sec. KKK-4. 36 MRSA §6162-A, as amended by PL 1997, c. 643, Pt. RR, §6, is repealed.
Sec. KKK-5. 36 MRSA §6162-B is enacted to read:
An individual is eligible for the elderly low-cost drug program if that individual meets the eligibility criteria set out in Title 22, section 254 and the following additional conditions.
1. Residence. An individual must be a legal resident of the State at the time the application is filed.
2. Limitation. An individual does not qualify under this program if that individual receives state supplemental income benefits or Medicaid benefits.
3. Appeals. The eligibility decision made by the State Tax Assessor or designee is final, subject to appeal in accordance with Title 5, chapter 375.
Sec. KKK-6. Report. The Department of Human Services shall report its progress in obtaining the Medicaid prescription drug waiver to the Joint Standing Committee on Appropriations and Financial Affairs and the Joint Standing Committee on Health and Human Services no later than October 1, 1999.
Sec. KKK-7. Appropriation. The following funds are appropriated from the General Fund to carry out the purposes of this Part.
1999-00
HUMAN SERVICES, DEPARTMENT OF
Low-cost Drugs to Maine's Elderly
All Other $1,092,000
Provides funds on a one-time basis for the additional costs associated with increased eligibility under this program.
Sec. KKK-8. Allocation. The following funds are allocated from Other Special Revenue funds to carry out the purposes of this Part.
2000-01
HUMAN SERVICES, DEPARTMENT OF
Medical Care - Payments to Providers
All Other $5,000,000
Provides funding for the State's share to expand coverage of prescription drugs for the State's elderly from the Fund for a Healthy Maine in accordance with the federal waiver referenced in section 2 of this Part.
Sec. KKK-9. Allocation. The following funds are allocated from the Federal Expenditures Fund to carry out the purposes of this Part.
2000-01
HUMAN SERVICES, DEPARTMENT OF
Medical Care - Payments to Providers
All Other $23,804,694
Provides funding for the federal share of prescription drugs for the State's elderly in accordance with the federal waiver referenced in section 2 of this Part.
Sec. KKK-10. Contingent effective date. Except for that section of this Part that repeals and replaces the Maine Revised Statutes, Title 22, section 3174-G, subsection 1-A and section 6 of this Part, this Part takes effect July 1, 2000 only if sufficient funds are available in the Fund for a Healthy Maine.
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