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NEW YORK's EPIC PROGRAM CASE LOAD WOULD DIMINISH 22% UNDER HOUSE MEDICARE PLAN

Executive Summary

The number of enrollees in the state of New York's elderly pharmaceutical insurance coverage (EPIC) program would diminish by 22% if the House version of the Medicare drug reimbursement plan were to pass, according to EPIC Research & Program Evaluation Director Susan Baird. "If the House bill were passed as it is, EPIC would lose 22% of our case load and we could face a reduction in cost of 57%," Baird told a March 14 workshop on public insurance programs for the elderly. The workshop was held during the American Pharmaceutical Association's annual meeting in Atlanta. The mandated Medicaid buy-in provision in both House and Senate bills could save EPIC $14 mil. a year, Baird noted. The provisions would require the state Medicaid agencies to cover drug charges under the deductible for Medicare beneficiaries with incomes below the federal poverty level. In addition to help from the federal program in covering seniors at the low-end of the financial spectrum, EPIC would also be helped by catastrophic care with wealtheir seniors. "We would lose individuals at both ends of the spectrum," Baird predicted. Once enrollees have spent above the $500 or $600 deductible level then the Medicare coverage would takeover for EPIC. EPIC began in October 1987. At full operation, the program is expected to cost $140 mil. annually, Baird said. In the state's first fiscal year, the program has planned expenditures of $10 mil. Through February, 70% of EPIC enrollees had filed a total of 273,000 claims under the program, Baird said. The majority of seniors purchased an average of nine prescriptions each. A small percentage of enrollees accounted for very high drug utilization, Baird noted: 7.2% accounted for 29% of all program expenditures. Expenditures for the period totaled $2.2 mil. To date, 3,300 pharmacies, or nearly 83% of pharmacies in the state, have enrolled, Baird noted. EPIC is the ninth state drug reimbursement initiative to get underway. The EPIC program offers two separate benefit plans for lower and moderate income individuals. Higher income seniors pay more to join the program and are expected to contribute more as the program goes on. The program also offers varying co-pays depending on income and marital status. The legislation establishing the EPIC program has a 1991 sunset provision, Baird noted. As a result, she explained, "before 1991, and on an ongoing basis in the interim, we are mandated to come up with evaluations that say how it is working and how it should work on an ongoing basis." EPIC was designed with a provision for annual increases in fees, premiums, deductibles and co-pays if costs exceed plan.
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