Indiana—authorizes its originally aged-only SPAP to supplement Part D Extra Help patients for up to $250 in drug cost-sharing yearly, but continues to exclude the disabled; and opened its health insurance risk pool to Medicare patients for secondary (including drug) coverage at reduced premiums—at least until ADAP payments get TrOOP credit.

Kansas---abolished its aged-only (age 67) SPAP, effective January 1, 2006.

Kentucky---created an aged-only SPAP to supplement Part D—which explicitly excludes the disabled—for those Medicare patients under 150% FPL.

Maryland---has 3 SPAP income bands—all but the highest income band one operate as Medicaid Pharmacy Plus waivers--that will supplement Part D; but only the lower income band (for those with incomes under about $890 monthly) covers anyone-- aged, disabled or not, on Medicare or not; the second income band--open only to Medicare patients with incomes up to 175% FPL, with high co-pays--excludes those disabled still in their 2 year waiting periods. The third income band offers limited benefits to even richer Medicare patients only.

Michigan---abolished its aged-only SPAP, effective January 1, 2006.

Mississippi—drops (as already scheduled) its present coverage of all aged and disabled with incomes under about 135% FPL on January 1, 2006, but then on the same date simultaneously creates a "Medicare-patients-only" Medicaid income level of 150% FPL—thus excluding those disabled still in their 2 year Medicare waiting periods (who will have to have income under the much lower $603 monthly SSI level to get Medicaid).

Missouri---instructed its previously aged-only SPAP to coordinate with, and supplement, Part D coverage for those with incomes under 150% FPL--now including the disabled on Medicare too, but not those disabled still in their 2 year Medicare waiting periods--but only as and when Part D becomes fully operational during 2006.

Montana—created a SPAP to pay up to $33.11 monthly in premiums only---not including deductibles, co-pays, coinsurance or drugs uncovered by Part D plans--for aged and disabled Part D patients under 200% FPL, but does not cover those disabled still in their 2 year Medicare waiting periods.

Nevada-- instructed its previously over-age-62-only SPAP to coordinate with, and supplement, Part D coverage for those under 225% FPL—and it will now include the disabled already on Medicare (and also include not only those disabled still in their 2 year Medicare waiting periods but even others with disabilities that are "verified", under SPAP rules, by local, state or federal agencies and or even by physicians).

New Hampshire-- authorized a SPAP to coordinate with, and supplement, Part D coverage for "all" (including disabled) Medicare patients under 150% FPL (but not those disabled still in the 2 year Medicare waiting period) but the state’s financing scheme—requiring patients to enroll in a favored Part D drug plan that would in return give the state enough in rebates to fund the SPAP----was forbidden by CMS.

New York—authorized its aged-only SPAP (EPIC) to coordinate with, and supplement Part D---but a bill to extend coverage to the disabled died in the legislature.

North Carolina---abolished its aged-only SPAP, effective January 1, 2006.

South Carolina---altered its aged-only SPAP to coordinate with, and supplement Part D for those under 200% FPL by paying 20% (that is, all except for a 5% coinsurance) of drug costs for those between 150% and 200% after they enter the donut hole and paying 10% (all except a 5% coinsurance) of the otherwise-applicable 15% coinsurance for those with incomes between 135% and 150% FPL after they pass what would be their donut hole threshold (if their incomes exceeded 150%). The state still excludes the disabled, on Medicare or not.

Wisconsin---its aged-only SPAP, operated as a Medicaid Pharmacy Plus waiver, was extended at least until mid-2007 by the state with CMS consent, but it still excludes the disabled, whether or not on Medicare.

Wyoming—the SPAP, once open to anyone (aged, disabled or not!) with income under 100% FPL, will be open only to anyone who is not a Medicare eligible (but it will continue to include those disabled still in their 2 year Medicare waiting periods) with income under 100% FPL after January 1, 2006.

Note: Other states with SPAPs---Connecticut, Delaware (capped annual benefit amount for disabled but not aged), Illinois (limited formulary for disabled but not aged), Maine, Massachusetts, New Jersey, Pennsylvania (covers aged only), Rhode Island (limited formulary for everyone; higher co-pays and age 55 minimum for disabled) and Vermont--- broadly authorized coordination with, and supplementation of, Part D benefits, but no others are known to have made major SPAP eligibility and coverage decisions.

Enactment of the Medicare Part D drug benefit means enormous savings to SPAPs---in addition to the savings states will get from Part D displacing some, but not all, state Medicaid drug expenses for dual eligibles. For example, Pennsylvania is estimated to have saved $150 million just from the preliminary Medicare interim $600 drug discount cards; New Jersey’s savings were $90 million; Connecticut’s were $15 million; and all SPAPs will save proportionately at least as much when the full, permanent Part D program becomes primary payer in 2006.

1.Since they'll realize large savings anyway, states should retain their own SPAPs to offer secondary, "wraparound" coverage to modest income patients who won't get all necessary drugs from the limited formularies that the privatized Part D Medicare drug plans will establish---and to help pay high cost-sharing that Part D plans will still impose (in spite of some "Extra Help" Low Income Subsidies) on limited-income patients---especially the 15% coinsurance for those with incomes between 135% and 150% of poverty.

2. With such great state budget savings at hand, those states with limited formularies or annual benefit caps---such as Delaware, Illinois, Indiana, Missouri and Rhode Island---can and should now cover all FDA-licensed drugs and remove any benefit caps.

3. With such large savings imminent, those state SPAPs which now cruelly exclude the disabled under age 65--- Indiana, New York, Pennsylvania, Rhode Island (age 55 minimum for disabled), South Carolina and Wisconsin--- should use a small part of the savings to finally cover them in their SPAPs.

4. Not only should all state SPAPs now cover the disabled---they must be attentive and compassionate enough to expressly cover those disabled who are still in their two year Medicare waiting period. These newly-disabled persons---who suffer from the recent onslaught of a serious illness or injury that usually requires even more medical care than longer-term, "stable" disabled persons, have just had a catastrophic drop in their incomes from having to stop working. Yet many of them get small Social Security Disability checks that are just above state Medicaid income levels---while not being covered yet by Medicare. States need to expressly tie their SPAPs' eligibility rules to being "over 65" or "disabled" --rather than simply being "Medicare-eligible" (which still excludes those in the two year waiting period). All SPAPs—except Nevada’s and Maryland’s lowest income band SPAP--- need to make this reform.

5. There may well be legal grounds to challenge state SPAPs that exclude the disabled. Not only do the Americans with Disabilities Act (ADA) and Section 504 of the 1973 Rehabilitation Act ban discrimination against the disabled in programs that, like these, are now arguably even more federally-related than before Part D’s passage; many states themselves have state constitutions, statutes, regulations or court decisions prohibiting discrimination against the disabled generally or in state programs. See, for example, "Exclusion from Services and the Americans with Disabilities Act" in Clearinghouse Review (October, 1996; pp.608-615). See also outlines of each state’s laws imposing state and local responsibilities for indigent health care under "State and Regional" at www.healthlaw.org .

a. Disabled Medicare patients are only one-sixth the number of aged beneficiaries (see Table 2-2, page 2-6, of 2004 Green Book at www.waysandmeans.house.gov ).

b. In the most on-point study of the issue, "Health Insurance Coverage Among Disabled Medicare Enrollees" in the Health Care Financing Review (Vol. 12, No. 4, pp. 27-37, Table 1 at p. 31), an official publication of HHS' Centers for Medicare and Medicaid Services, reported that 41% of disabled Medicare patients already have secondary private health insurance. The accompanying text makes clear that this is almost always as covered dependents in the job health plans (with drug benefits) of their working-aged, healthy spouses; aged Medicare patients, by contrast, are typically married to other elderly, retired spouses and so neither spouse has employee health coverage anyway. Hence, nearly half of the disabled won't even need to apply for state SPAP coverage.

c. Demographic data tables on veterans by age band for 2001 at www.VA.gov and the 2000 census figures for all male age bands over 65 at www.census.gov , read together, indicate that over 60% of men over age 65 are military veterans---meaning that, if they have honorable or general discharges and income under about $30,000, they're eligible for prescriptions for $7 each (with a zero co-pay for those with family incomes under about 110% FPL) from the VA ! (And, by getting their health care from the VA, limited income patients would actually be much better off and even avoid high, unaffordable Medicare deductibles and co-pays, since the VA has few--and very low—co-pays itself.) Even though-- because they are state-funded and subject to the states' own eligibility rules---SPAPs can insist that applicants who are VA-eligible go there for drugs instead, they have unaccountably so far failed to do so, even though they’d save many millions. If they began doing so, they could shift large costs to the VA instead---and thus be all the more able to afford covering the disabled under age 65!

(The Kentucky AIDS Drug Assistance Program [ADAP], which serves a considerably younger population, with many fewer veterans, than is found in SPAPs---because, since its 1973 abolition, the draft hasn't been there to force many younger men to serve, even though it did force most older men into the military when they were young---still was able to identify a full 10% of its caseload as VA-eligible simply by asking clients about military service. (Email Lisa.Daniel@mail.state.ky.us for details.) SPAPs, if they asked too, could find even more of their clients to send to the VA instead---and they'd thereby save more than enough money to cover the disabled.

d. Although it's possibly not an argument that should be made publicly---for one thing, it's not likely to influence some more conservative state officials---keeping current state SPAPs operating, and expanding them to cover the disabled too (including those in their two year waiting periods) where they currently fail to do so, will make these SPAPs more widely available to needy disabled AIDS patients also. That would lessen the growing, unfunded burden on hard-pressed state ADAPs, many of which have been forced to place ill, uninsured applicants on waiting lists.