Health Reform WK-EDGE Access, transparency part of Medicare Part C, D changes
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Friday, February 21, 2020

Access, transparency part of Medicare Part C, D changes

By Anthony H. Nguyen, J.D.

CMS looks to address access and coverage under Medicare Advantage (Part C) and Part D drug programs.

CMS is proposing a requirement for prescription drug plans under Medicare Part C and Part D to offer real-time pricing comparisons of out-of-pocket payments for different prescription drugs to beneficiaries. This proposal is part of the agency’s initiative to expand coverage of generic drugs or to incentivize the Part D plans to push beneficiaries to use lower-cost drugs. In addition to the pricing comparisons CMS would lower beneficiary cost sharing on specific prescription drugs and promote the use of generic drugs. The proposed rule would also implement opioid provisions from the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act and codify existing policies under Part C and D related to supplemental benefits and special election periods (Proposed rule, 85 FR 9002, February 18, 2020).

Real-time pricing. Beginning January 1, 2022, real-time drug price comparison tools would be available for consumers to shop for lower-cost alternative therapies under their prescription drug benefit plan. CMS noted that beneficiaries would be able to compare drug prices at the doctor’s office to find the most cost-effective prescription drugs. For example, if a doctor recommends a specific cholesterol-lowering drug, the patient could look up what the copay would be and see if a different, but similarly effective option might be available. According to the agency, patients would be better positioned to know costs before paying at a pharmacy, and drug makers and plans would be forced to compete on the basis of the costs that patients face for their prescription drugs.

Part D tiers. Under Medicare Part D, beneficiaries choose the prescription drug plan that best meets their need; typically these plans place drugs into different tiers of coverage based on formularies. Currently, all drugs on a plan’s specialty tier, the tier that has the highest-cost drugs, have the same level of cost sharing. The proposed rule would allow a second, preferred specialty tier in Part D with a lower cost sharing amount.

CMS is also seeking comment on potentially developing measures of generic and biosimilar utilization in Medicare Part D as part of a plan’s star rating. This would reward plans based on the rate at which they encourage market adoption of these competitor products and lower costs for patients.

Quality ratings and measures. In addition to routine measure updates and technical clarifications to the Part C and D plan star ratings, CMS would attempt to reduce the influence of outliers in its ratings by increasing measure weights for patient experience or complaints and access measures from two to four.

Additionally, under the Part D program, plans do not have to disclose to CMS the measures they use to evaluate pharmacy performance in their network agreements, which impacts pharmacy reimbursements. Under the proposed rule, CMS would require Part D plans to disclose such information in order for the agency to track how plans are measuring and applying pharmacy performance measures. CMS will also be able to report this information publicly to increase transparency on the process.

Medicare Advantage. Beneficiaries with End-Stage Renal Disease (ESRD) are only allowed to enroll in Medicare Advantage plans in limited circumstances. The proposed rule would change that by implementing 21st Century Cures Act requirements to give all beneficiaries with ESRD the option to enroll in a Medicare Advantage plan starting in 2021. ESRD patients would have access to more Medicare coverage choices and extra benefits such as transportation or home-delivered meals.

For 2020, Medicare Advantage beneficiaries would also be able to access additional telehealth benefits not offered under Medicare Fee-for-Service, including services at home, rather than requiring them to go to a health care facility. CMS would give Medicare Advantage plans more flexibility to count telehealth providers in certain specialty areas like psychiatry, neurology, or cardiology towards network adequacy standards, which would encourage greater use of telehealth services as well as increase plan choices for beneficiaries

Opioids. The proposed rule would implement provisions from the SUPPORT Act that require Part D plans to educate beneficiaries on opioid risks, alternate pain treatments, and safe disposal of opioids. The proposed rule would also expand drug management programs and medication therapy management programs, through which Part D plans review with providers opioid utilization trends that may put beneficiaries at-risk and provide beneficiary-centric interventions.

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