Glenn Liebman, CEO
Mental Health Association in New York State, Inc.

Testimony to

JOINT BUDGET HEARINGS OF THE NEW YORK STATE
SENATE AND ASSEMBLY ON HEALTH AND MEDICAID

Thank you very much, Chairmen Johnson and Farrell, Senator Hannon and Assemblymember Gottfried, for providing us with the opportunity to submit testimony regarding Governor Pataki’s 2006-07 Executive budget proposal. We appreciate the opportunity to explain our perspective regarding issues contained in this portion of the Governor’s budget proposal that impact people living with mental health needs throughout this state.

Briefly, the Mental Health Association in New York State, Inc. (MHANYS) is comprised of 30 affiliates across New York State representing 54 counties. Our affiliates vary greatly in their size and the services they provide – from small organizations that simply provide education and advocacy about mental health, to mental health service providers, often times the largest within a region.

Many people with mental health needs are reliant upon programs, such as Medicaid, to keep them healthy and stable. Without these programs, many people would deteriorate to the point where they need hospitalization or end up entangled with the criminal justice system.

It is for this reason that MHANYS is concerned about many of the Governor’s proposals with regard to the health portion of the budget, which includes funding for Medicaid and other crucial programs. As an active member of the Medicaid Matters New York coalition, we wholeheartedly support the positions this organization takes, many of which are outlined below.

Medicare Part D

This year, perhaps of greatest concern to us are issues related to the state’s response to the Federal government’s new prescription drug coverage program, otherwise known as Medicare Part D. Over the past year, MHANYS has played an active role in assisting people with mental health needs, many of whom are on both Medicare and Medicaid (dual eligibles), make the mandatory transition to Medicare as the primary provider of medications. This changeover has been less than smooth, causing many people to go without the medications that allow them to remain healthy and stable. Problems have arisen due to computer glitches, mass confusion about how the benefit is supposed to work, and the inability of many to pay the now-mandatory co-pays required to access medications under the new drug benefit, which were not required under Medicaid.

As the January 1st implementation date approached, many advocates for dual eligibles were relieved by the Pataki administration’s promises to provide “wrap around” coverage to dual eligibles denied medications under their Part D plan. Indeed, we are very pleased that the Governor has provided this coverage for dual eligibles via executive orders extended on a weekly basis. However, we were alarmed to see that the Governor’s proposal would eliminate such “wrap around” coverage under Medicaid on July 1st, except for certain mental health, HIV/AIDS, and transplant medications. While we are pleased that “wrap around” coverage for some mental health medications would continue, the health needs of those living with mental illness often go far beyond mental health medications. In this regard, we believe that such “wrap around” coverage for medications denied under a Part D plan to a dual eligible should be continued at least until the end of the 2006-07 fiscal year. This would allow for a thorough examination of the status of the new Medicare prescription drug benefit and any continued problems with accessing medications one year after implementation.

Another major barrier to successful implementation of Medicare Part D for dual eligibles has been the mandatory co-payments required for accessing medications under this new benefit. Under Medicaid, if an individual was unable to make such a co-payment, access to a medication could not be denied. Now, if an individual is unable to produce the co-payment under Medicare, unless the pharmacist covers the co-pay, that person will be forced to leave the pharmacy without their medications. We strongly support any efforts the state can take to help dual eligibles unable to pay the mandatory co-payments, which would ensure continued access to their medications.

Preferred Drug Program

For the past several years, MHANYS has remained opposed to the implementation of a Preferred Drug Program (PDP) under Medicaid for fear that such a program would restrict access to medications for people with complex health needs, including those living with mental illness. While we were disappointed that the PDP was enacted last year, several safeguards were included in the final legislation that created additional patient protections; 1) atypical anti-psychotic and anti-depressant medications were exempted from the provisions requiring prior authorization; 2) consumer representation was included on the Pharmacy and Therapeutics (P & T) Committee; 3) considerations about cost were specifically excluded from the factors used to determine which drugs would be ‘preferred’, and; 4) the physician was given the authority to make the final decision about which medication a patient would get, not the program administrators.

Many of these safeguards are crucial to the safe implementation of this program. However, we have been very disappointed to see many areas in which these safeguards have not been honored. First, is in the composition of the Pharmacy and Therapeutics Committee, which is supposed to include 3 consumer representatives – only one has been appointed so far. Second, is the requirement for a doctor to get prior authorization before prescribing a long-lasting, injectible atypical anti-psychotic, despite the fact that the law specifically states that “no prior authorization shall be required under the preferred drug program for: (a) atypical anti-psychotics…”

Now, the Governor’s budget proposal includes recommendations to eliminate the ability of the doctor to make the final determination about which drug a patient will get. In addition, the Governor also wants cost to be considered when determining which drugs should require prior authorization under the PDP. These proposals, in concert with the failure to adhere to the specifics of the law authorized by the Legislature, give us great concern.

We strongly urge the Legislature to reject these attempts by the Governor to eliminate these crucial safeguards. In addition, we hope the Legislature will examine the P & T Committee’s authority to make decisions without the complete Committee having been appointed, and to examine the authority of the PDP to require prior authorization for classes of medications specifically identified in the law as exempt.

We also hope that the Legislature will require the Department of Health to continue to provide 30 days notice of upcoming P & T Committee meetings and of any decisions, rather than reducing that window of time to 10 days.

Adult Homes

Over the last several years, we were pleased to see that the administration had committed millions of dollars to adult home reform. Last year, the Governor and Legislature’s provision of an SSI increase to adult home residents translated to a much needed $19 per month increase in the Personal Needs Allowance for each resident. However, this year, a notably glaring omission in the Governor’s health budget proposal is in the area dealing with adult homes.

As part of the New York State Coalition for Adult Home Reform (NYSCAHR), we asked the Governor to include funding for the following initiatives in his budget proposal: creation of more independent settings; assistance to help people move through the creation of housing assistance application programs; supportive congregate housing; legal and lay advocacy; air conditioning for residents; independent case management, and; assistance to help adult home recipients cover the now mandatory co-payments required under Medicare Part D. Despite these requests, there is only $2.75M for a range of services and expenses related to adult home initiatives, which could include legal and lay advocacy and for grants under the EnAble program.

In a recent letter to the Governor, NYSCAHR encouraged the Governor to include $5.25M in funding for independent case managers, $5M for air conditioning, $1.5M for housing assistance application programs, and $1M for legal and lay advocacy. MHANYS also urges supports efforts to provide additional funding for programs designed to help individuals in adult homes gain additional recovery-oriented services that would help them live successfully in the community.

Family Health Plus

Last year, we were pleased that the Legislature rejected the Governor’s proposed elimination of coverage for mental health services under Family Health Plus. This year, we urge you to reject the Governor’s proposal to greatly increase co-payments for emergency services, and also reject his recommendation that all co-payments be a mandatory component of accessing care under this program.

Mandatory Enrollment of SSI Beneficiaries in Managed Care

As part of the administration’s proposal, the Governor calls for the acceleration of the mandatory enrollment in managed care for SSI recipients. He also plans to require that all individuals with a serious and persistent mental illness (SPMI) be required to enroll in managed care for their health coverage, leaving all mental health coverage in a fee-for-service model (due to statutory restrictions). These components are included in the budget solely due to their projected savings – the Governor has the administrative authority to make these changes and does not require Legislative approval for these actions. However the Governor does require Legislative authorization to change the minimum number of managed care providers that must be present in a county in order for SSI recipients to be mandated to enroll in a HMO. The Governor’s proposal would change this from two to one provider.

We are very concerned about the impact that such a proposal could have on the overall healthcare that an SSI recipient receives. It is our concern that such a change would bifurcate health care for individuals on SSI with mental illness, with no communication between the mental health service provider(s) and those providing the rest of the person’s health care under the managed care model.

One of MHANYS’ goals is to ensure that integration between mental and physical health care exists. Only through legislation or regulation can such integration be assured.
The case management available to all individuals under the managed care model must incorporate all aspects of that person’s health, including all mental health and other care that person is receiving, even if those services are not provided by the managed care company.

With regard to the change that would require mandatory enrollment in managed care for all SSI recipients in counties where there is only one provider, we believe that such a mandate should only be imposed on those living in counties where a choice of managed care organizations exists.

Conclusion
Once again, thank you for the opportunity to provide you with our thoughts in regard to the Governor’s budget proposal. In summary, though we are appreciative of the proposed carve out of mental health drugs in the PDP, we have great concerns with the overall PDP, as well as other proposed Medicaid cuts - including the elimination of mental health coverage from Family Health Plus. With regard to Medicare Part D, we sincerely hope that the state will take all actions possible to make this change in prescription drug coverage as painless as possible through “wrap around” coverage and assistance with co-pays. We thank you very much for providing us with the opportunity to share our thoughts regarding the Governor’s budget proposal.