Access and Utilization of New Antidepressant and Antipsychotic Medications. F. Federal and State Programs (HCFA(now known as CMS), IHS, CHAMPUS, VA, Medicaid)

01/01/2000

The Health Care Financing Administration(now known as Centers for Medicare and Medicaid Services(CMS)) (HCFA(now known as CMS)) and the Indian Health Service (IHS) were automatically selected without the use of specific criteria in order to provide a necessary background behind federally-operated and state- or tribally-administered public insurance programs. More specifically, HCFA(now known as CMS) handles the administration of the publicly funded programs, Medicaid and Medicare. The IHS is responsible for the Native American population which has a documented prevalence of behavioral health disorders in its communities.

The Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) and the Veteran's Administration (VA) were selected as additional federal interviews, but ones that provide more narrow perspectives, largely dictated by the specific populations served under each program. Under CHAMPUS, active duty individuals and their dependents along with retirees are covered, while the VA covers those individuals who were in active duty but retired due to a service-related disability or are a dependent of a veteran. These two perspectives present unique snapshots as Federal programs instituted on an individual basis through treatment facilities (CHAMPUS) or networks (VA). Additionally, the CHAMPUS viewpoint provides and interesting perspective into the social and cultural issues associated with serving in the military with a diagnosed mental illness.

On the state level, four Medicaid programs were selected based on the following criteria:

  • Represent geographic diversity;
  • Offer range of benefits from generous to less comprehensive;
  • Utilize a variety of reimbursement mechanisms (i.e., managed care, fee-for-service); and
  • Structure behavioral health and pharmaceutical services in different ways (i.e., integrated, carve-out).

As such, California, Georgia, Texas, and Wisconsin were selected. Each state handles the administration of its behavioral health and pharmacy benefit in a slightly different manner and each state has different restrictions attached to its formulary and/or prescription coverage.

Program
(Covered Lives)
Reason for Inclusion
Federal
HCFA(now known as CMS)
  • Essential
Indian Health Service, Navajo Region (201,583)
  • Covers a special needs population
  • Pharmacist involvement is progressive
  • Navajo nation is large
Department of Defense (8 million)
  • Offers variety of managed care products
  • National formulary as well as individual military treatment facility formularies
Veteran's Administration (10-11 million)
  • National formulary as well as individual formularies

State

California (4.9 million)
  • Largest state program
  • Reputation for restrictive formularies
  • Combination of FFS and MC for behavioral health
Texas (2.5 million)
  • Moving Houston and Dallas behavioral health into MC
  • Has a reputation for poor coverage for behavioral health (BH)
  • State-approved treatment algorithms for mental illness (TMAP) have drawn attention for being progressive
Georgia (1.2 million)
  • Mental health still in fee-for-service
  • Restrictions of number of prescriptions allowed per patient per month (5)
  • Legislature considering bill to mandate coverage for all FDA-approved drugs by all insurance providers
Wisconsin (390,000)
  • Uses an integrated Medicaid MC program
  • Five BH carve-outs for special needs programs
  • Considered a leader in innovative, comprehensive programs