The Number Of MA Plans Offering Supplemental Benefits Continues To Rise, Study Finds

Medicare Advantage

Source: Fierce Healthcare, by Paige Minemyer

The number of Medicare Advantage plans that offer supplemental benefits continues to grow, according to new data from the Better Medicare Alliance.

The analysis, conducted by Milliman, found the number of plans offering such benefits increased across 36 out of 41 categories from 2020 to plan year 2021. That includes increases across 15 of 17 traditional supplemental benefit categories, four of five new expanded categories and 17 of 19 supplemental benefits for the chronically ill categories.

For example, 57% of plans now offer a meal benefit, and 46% will cover members’ transport to and from doctors’ visits.

The most common benefits offered, according to the report, include vision (offered by 96% of plans), hearing (93%), fitness (92%) and dental care (87%).

“This analysis provides unique insight into the ways that Medicare Advantage continues to innovate and enhance benefit offerings, even in the face of the extraordinary circumstances presented by the COVID-19 pandemic,” said Allyson Schwartz, CEO of the Better Medicare Alliance, in a statement.

“The growth of extra benefits and lower out-of-pocket available to seniors, including those particularly targeted to individuals with chronic conditions, demonstrates the value that Medicare Advantage continues to deliver for millions of beneficiaries,” Schwartz said.

For benefits targeting chronic conditions specifically, diabetics were the most targeted patient population, the study found. In the 2021 plan year, 293 Medicare Advantage plans offered lower cost sharing and/or additional benefits targeting members with diabetes, reaching close to 1.5 million people.

The number of plans offering supplemental benefits for members with behavioral health diagnoses also grew significantly in 2021, according to the analysis, growing from just five plans in 2020 to 135 plans.

In addition, benefits targeting chronic obstructive pulmonary disorder and congestive heart failure were also common, the study found.

CMS Pauses Three Trump-Era Proposed Rules

CMS pauses three Trump-era proposed rules

Source: America’s NewsHub, by Marie Maynes

CMS on Tuesday paused three proposed rules developed under the Trump administration.

The proposed rules would affect in-center dialysis coverage requirements for third-party payment programs, enable seniors to keep their Social Security retirement benefits if they opt out of Medicare Part A coverage and increase oversight of accrediting organizations. The White House budget office had been reviewing all three rules.

CMS withdrew the proposed rules following a memo last week from White House Chief of Staff Ron Klain directing agencies to freeze new regulations that hadn’t taken effect. The moves don’t take any of the policies off the table, but the Biden administration won’t sign off on any rules until it’s had a chance to review them. HHS froze a new regulation targeting community health centers’ 340B drug discounts last week.

The Obama administration signed off on an interim final rule forcing dialysis centers to inform their patients each year about all their public and private coverage options and third-party premium assistance. The rule also made dialysis centers tell health plans which individual market policies they were subsidizing.

The policy was meant to address concerns that some healthcare providers were steering patients into individual market coverage because it was in providers’ best interest. The rule took effect shortly before former President Donald Trump took office. An updated, permanent version of the regulation had been working its way through the rulemaking process but had been under review by the White House Office of Management and Budget since June 2019.

The Trump administration was also working on a proposal to allow seniors to collect Social Security retirement benefits if they chose not to accept Medicare coverage for inpatient services. Under the current rules, a person age 65 or older automatically applies for Part A coverage when they file to collect Social Security benefits.

The policy would have threatened “the universality of the program, which is vital to preserving its solvency and popularity,” according to the Kaiser Family Foundation. “Those most likely to opt out would likely be healthier and wealthier than average.”

OMB was reviewing a proposed rule from CMS in response to its request for information in December 2018 asking for feedback from accreditors like the Joint Commission regarding how they establish and disclose relationships with providers they both sell consulting services to and accredit for participation in Medicare. The proposed rule would recommend new requirements for accrediting organizations to conduct surveys.

4 Vital Health Issues — Not Tied to Covid — That Congress Addressed in Massive Spending Bill

4 Vital Health Issues — Not Tied to Covid — That Congress Addressed in Massive  Spending Bill | Kaiser Health News

Source: Kaiser Health News, by Emmarie Huetteman

Late last month, before President Joe Biden took office and proposed his pandemic relief plan, Congress passed a nearly 5,600-page legislative package that provided some pandemic relief along with its more general allocations to fund the government in 2021.

While the $900 billion that lawmakers included for urgent pandemic relief got most of the attention, some even bigger changes for health care were buried in the other parts of that huge legislative package.

The bundle included a ban on surprise medical bills, for example — a problem that key lawmakers had been wrestling with for two years. Starting in 2022, because of the new law, patients generally will not pay more for out-of-network care in emergencies and at otherwise in-network facilities.

But surprise bills weren’t the only health care issue Congress addressed as it ended a tumultuous year. Lawmakers also answered pleas from strained health facilities in rural areas, agreed to cover the cost of training more new doctors, sought to strengthen efforts to equalize mental health coverage with that of physical medicine and instructed the federal government to collect data that could be used to rein in high medical bills.

Here are some details about those big changes Congress made in December.

Rural Hospitals Get a Boost

Throwing a lifeline to struggling rural health systems — and, it appears, a bone to an outgoing congressional committee chairman — lawmakers gave rural hospitals a way to get paid by Medicare for their services regardless of whether they have patients in beds.

The law creates a new category of provider, known as a “rural emergency hospital.” Starting in 2023, some hospitals will qualify for this designation by maintaining full-time emergency departments, among other criteria, without being required to provide in-patient care. The Department of Health and Human Services will determine how the program is implemented and which services are eligible.

Medicare, the federal insurance program that covers more than 61 million Americans 65 and older or with certain disabilities, currently does not reimburse hospitals for emergency or hospital outpatient services unless the hospital also offers in-patient care.

That requirement has exacerbated financial problems for rural hospitals, many of which balance serving communities with fewer patients — and less need for full in-patient services — with the need for emergency and outpatient services. One study last year found 120 rural hospital facilities had closed in the past 10 years, with more at risk.

Hospital groups have praised the change, which was introduced by Sen. Chuck Grassley (R-Iowa), who has championed rural health issues and ended his term as chairman of the Senate Finance Committee this month. “I worked to ensure rural America would not go overlooked,” he said in a statement.

Medicare Invests in More Doctors

Hoping to address a national shortage of doctors that has reached critical levels during the pandemic, Congress created an additional 1,000 residency positions over the next five years.

Medicare will fund the positions, which involve supervised training to medical school graduates going into specialties like emergency medicine and are distributed among hospitals most in need of personnel, including rural hospitals.

Critics like The Wall Street Journal’s editorial board have noted this is Congress’ attempt to fix a problem it created in the late 1990s, when lawmakers capped the number of Medicare-funded residency positions in the United States, fearing too many doctors would inflate the cost of Medicare.

While Medicare is not the only source of educational funding and hospitals may add their own residency slots as needed, Medicare generally will reimburse hospitals for the number of residents they had at the end of 1996. Among other consequences of that 1996 cap, most Medicare-funded residencies are clumped at Northeastern hospitals, a 2014 study showed.

In contrast to the 1,000 positions created as part of the stimulus package, one bipartisan proposal in 2019 that was never enacted would have added up to 15,000 positions over five years.

Strengthening Mental Health Parity

The legislative package strengthens protections for mental health coverage, requiring federal officials to study the limitations insurance companies place on coverage for mental health and substance use disorder treatments.

In 1996 Congress passed the first law barring health insurers from passing along more of the cost for mental health care to patients than they would for medical or surgical care. The Affordable Care Act, building on earlier laws, made mental health and substance use disorder treatments an “essential health benefit” — in other words, it required most health insurance plans to cover mental health care.

But enforcing that standard has been a challenge, in part because violations can be hard to spot and the system has often relied on patients to notice — and report — them.

In December, lawmakers approved a measure requiring insurers to analyze their coverage and provide their findings to state and federal officials upon request.

They also instructed federal officials to request the findings from at least 20 plans per year that may have violated mental health parity laws and tell insurers how to correct any problems they find — under penalty of having insurer violations reported to their customers if they do not comply.

The law requires federal officials to publish an annual report summarizing the analyses they collect.

More Transparency in Cost and Quality

Americans often do not know how much they will be expected to pay when they enter a doctor’s office, an ambulance or an emergency room.

Taking another modest step toward transparency, Congress banned so-called gag clauses in contracts between health insurers and providers.

Among other things, these sorts of “gag” restrictions previously have prevented insurers and group health plans from sharing with patients and others — such as employers — information about a provider’s prices or quality. The December legislation also prohibited insurers from agreeing to contracts that prevent them from getting access electronically to claims and other information from providers on behalf of the insurer’s enrollees.

In 2018, Congress banned gag clauses in contracts between pharmacies and insurers or pharmacy benefit managers. Those gag clauses had prevented pharmacists from sharing cost information with patients, like whether they could pay a lower price for a prescription by paying out-of-pocket rather than using their insurance coverage.

The proposal approved in December’s legislation came from a big, bipartisan package of health care cost fixes passed in 2019 by the Senate Health, Education, Labor and Pensions Committee, but not by the rest of Congress. The committee’s Republican chairman, Sen. Lamar Alexander of Tennessee, retired from Congress this month. His Democratic partner on that package, Sen. Patty Murray of Washington, will take over the chairmanship as Democrats assume control of the Senate and has vowed to focus on health care affordability.

Consumers First, a health consumer-focused alliance of health professionals, labor unions and others, led by Families USA, praised the ban. The change is “a significant step forward” to stop “the abusive practices from hospitals and health systems and other segments of the health care sector that are driving up health care costs and making health care unaffordable for our nation’s families, workers, and employers,” it said in a statement.

CMS Finalizes Drug Transparency, Pharmacy Quality Rules

CMS finalizes drug transparency, pharmacy quality rules

Source: Fyne Fettle, by James Schneider

CMS on Friday finalized a rule it estimates will save the federal government $75.4 million over the next decade in Medicare Advantage and Part D payments, with the agency crediting cost-savings to several measures enacted to curb prescription drug spending.

Under the new rule, CMS expanded drug and medication therapy management programs that require Medicare Part D plans to review potentially-risky opioid use trends with providers and patients. The final law also requires Medicare Part D sponsors to report payment suspensions against pharmacies facing fraud allegations to CMS, falling in line with the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act, also known as the SUPPORT Act. The legislation also mandated Medicare Advantage and Part D plan sponsors report inappropriate opioid prescriptions and insurers’ actions to CMS via a secure internet portal.

In addition to cracking down on providers’ opioid prescriptions, the new rule includes steps to reduce out-of-pocket drug costs for Part D beneficiaries, standardize insurers’ process for reviewing pharmacy quality and allow enrollees to know more about their prescription drug costs in advance. The new rule follows an earlier set of Medicare Advantage and Part D updates CMS made in May 2020.

CMS will now require insurers to tell the agency how they calculate pharmacy performance measures by January 1, 2022, after complaints from the pharmaceutical industry the criteria used were unfair. CMS will publicly report the metrics to help insurers standardize the process for reviewing pharmacy performance, the agency said.

The federal agency will also give Part D plans the ability to create a “preferred” specialty tier of high-cost drugs with lower cost-sharing for enrollees by January 1, 2022. That change could help negotiate lower prices for expensive medications with drugmakers by promising them access to the so-called preferred tier.

Continuing the Trump administration’s efforts to reduce healthcare spending through increased transparency and lower drug costs, CMS wants Part D prescription drug plans to offer beneficiaries access to patient-specific drug costs in real-time by January 1, 2023. As an example, CMS said this tool will allow consumers to compare the price of similar, cholesterol-lowering drugs to see which requires the lowest individual copay. The final rule pushes this requirement back a year from its initial proposal.

“The changes in this final rule provide desperately needed transparency on the out-of-pocket costs for prescription drugs that have been obscured for seniors,” CMS Administrator Seema Verma said in a statement. “It will strengthen Part D plans’ negotiating power with prescription drug manufacturers so American patients can get a better deal.”

The final rule also updates Star Ratings and Quality Bonus Payment ratings, although CMS did not give details on the specific changes. The agency added that it is also working to codify policy changes related to supplemental benefits and provisions aimed at reducing the administrative burden for Programs of All-Inclusive Care for the Elderly, or PACE.

CMS Will Raise Medicare Advantage Plan Payments By 4.08% In 2022

Medicare Advantage plans will get a 1.66% pay bump for 2021

Source: Fyne Fettle, by James Schneider

CMS will raise Medicare Advantage plan payments by 4.08%, the agency announced Friday.

It also signed off on its controversial proposal to complete a multiyear phase-in of a new payment methodology. The new process will adjust plan payments using diagnoses solely from encounter data—information created by healthcare providers about patients’ medical conditions and treatment. The health insurance industry has long railed against the use of encounter data to adjust their payments. They argue that the data is incomplete and often inaccurate and that using it would lead to lower payments to Advantage plans.

“This announcement is being made nearly three months earlier than usual to provide MA organizations and Part D sponsors more time to take this information into consideration as they prepare their bids for 2022,” CMS said in a fact sheet.

CMS also approved a 5.90% coding pattern adjustment for Advantage plans, which is the lowest adjustment allowed under the law. It also cemented previously approved changes to Medicare Part C and D Star Ratings.

California Budget Reflects ‘Pandemic-Induced Reality,’ Governor Says

LOS ANGELES, CALIFORNIA - DECEMBER 14: Gov. Gavin Newsom holds up a vial of the Pfizer-BioNTech COVID-19 vaccine at Kaiser Permanente Los Angeles Medical Center on December 14, 2020 in Los Angeles, California. The first doses of the vaccine are being administered to frontline workers in hospitals across the country today. (Photo by Jae C. Hong-Pool/Getty Images)

Source: Kaiser Health News, by Angela Hart

The coronavirus pandemic doomed Gov. Gavin Newsom’s ambitious plans last year to combat homelessness, expand behavioral health services and create a state agency to control soaring health care costs.

But even as the pandemic continues to rage, California’s Democratic governor said Friday he plans to push forward with those goals in the coming year, due to a rosier budget forecast buoyed by higher tax revenue from wealthy Californians who have fared relatively well during the crisis.

Newsom’s $227.2 billion budget blueprint also prioritizes billions to safely reopen K-12 schools shuttered by the pandemic, $600 payments for nearly 4 million low-income Californians — in addition to federal stimulus payments — and coronavirus relief grants and tax credits for hard-hit small businesses.

However, his 2021-22 fiscal year spending plan does not include additional public health money for local health departments steering California’s pandemic response, which have been chronically underfunded. He vowed to support cities and counties by boosting state testing and contact tracing capacity, speeding vaccination efforts and funding state-run surge hospitals that take overflow patients.

Newsom said Friday his budget reflects a “pandemic-induced reality” with investments aimed at spurring California’s economic recovery by helping businesses and people living in poverty. Wealth and income disparities, he added, “must be addressed.”

But Democrats in control of the state legislature, county leaders and social justice groups say that will be difficult to achieve because Newsom’s spending plan does not sufficiently fund health and social safety-net programs.

And without additional public health money, local leaders worry California will not be able to adequately control the spread of the virus.

“County public health is drowning,” said Graham Knaus, executive director of the California State Association of Counties. “We are triaging right now between testing, contact tracing and vaccination, and it’s impacting the response to the pandemic.”

Newsom’s budget proposal is the first step in a months-long negotiation process with the Democratic-controlled legislature, which has until June 15 to adopt the state budget that takes effect July 1. Lawmakers have become increasingly frustrated with the governor’s response to the pandemic, including his unilateral spending decisions in response to the emergency. Newsom is also facing a burgeoning recall effort, backed by heavyweight Republicans such as former San Diego Mayor Kevin Faulconer, who is considering challenging Newsom in the 2022 California gubernatorial election.

Newsom said he expects to make some tough calls on spending even though the state anticipates a $15 billion budget surplus for the coming fiscal year, largely because a state fiscal analysis projected deficits in subsequent years.

“While we are enjoying the fruits of a lot of one-time energy and surplus, it’s not permanent and we have to be mindful of over-committing,” Newsom said, explaining why he didn’t include funding to expand Medicaid to more unauthorized immigrants.

Some lawmakers say they will nonetheless press Newsom to use higher-than-expected revenues — and perhaps seek new taxes — to expand health coverage to more Californians.

The following health care proposals factor heavily into Newsom’s 2021-22 budget proposal.

Covid Relief

Newsom committed $4.4 billion in his budget to vaccine distribution, increased testing, contact tracing and other short-term pandemic expenses. Because that spending is related to the public health emergency, the state expects at least 75% to be reimbursed by the federal government and insurance payments.

He also proposed $52 million to fund costs at state-run surge hospitals, including support staff. And he is asking lawmakers to sign off on a covid relief package that would provide funding before the start of the fiscal year in July. It would include $2 billion to help school districts reopen classrooms to in-person instruction beginning in February by paying for protective equipment, ventilation systems and adequate testing. It would also commit billions to economic recovery, such as stimulus payments for individuals, and grants and tax credits for struggling small businesses.

Newsom also wants to increase the budget for the Department of Industrial Relations by $23 million to fund up to 113 additional workplace inspectors at the California Division of Occupational Safety and Health to police health order violations at businesses and enforce workplace safety laws.

Transforming Medi-Cal

Spending for Medi-Cal, the state’s Medicaid program for low-income residents, is expected to grow in the coming year because of the economic impact of the pandemic — as is its enrollment. The program has roughly 13 million enrollees, or about one-third of the state population.

In the coming year, Newsom will also press forward with a major overhaul of Medi-Cal, through a project called CalAIM, to provide new benefits emphasizing mental health care and substance use treatment, and pay for some nontraditional costs such as housing assistance. The hope is the program would divert homeless and other vulnerable people away from expensive emergency room care and keep them out of jail.

State Medi-Cal officials estimate the program would cost $1.1 billion for the first year. The state is working with the federal Centers for Medicare & Medicaid Services to obtain approval for the program.

Newsom also wants to expand Medi-Cal benefits to cover over-the-counter cold medicine and blood glucose monitors for people with diabetes. His budget includes $95 million for a major expansion of telehealth services that would permanently provide higher payments for virtual doctor visits.

Controlling Health Care Costs

Newsom is proposing a new state agency, the Office of Health Care Affordability, which he said would help control health care costs. He budgeted $63 million over the next three years for the office, which would set health care cost targets for the health care industry — along with financial penalties for failing to meet future targets.

Powerful health industry groups said they are still assessing whether they will support the proposal. But some expressed concern last year when Newsom floated the idea. Doctors and hospitals routinely fight proposals in Sacramento that might limit their revenue.

Newsom acknowledged Friday the task would be “tough.”

Battling Homelessness and Food Insecurity

Newsom is proposing a one-time infusion of $1.75 billion to battle homelessness.

Of that, Newsom said, $750 million would help counties purchase hotels and transform them into permanent housing for chronically homeless people. Another $750 million would allow counties to purchase facilities to treat people with mental illness or substance use disorders. And $250 million would help counties purchase and renovate homes for low-income older people.

Newsom’s budget also includes $30 million to help overwhelmed food banks and emergency food assistance programs.

Lawmakers said they plan to negotiate for even more funding for homelessness and safety-net programs.

“We absolutely need to significantly increase our investment to address homelessness because the need is so intense,” said Assembly member David Chiu (D-San Francisco). “And I don’t think there’s a single legislator who isn’t incredibly concerned about the food insecurity we’re seeing: lines around the block for food banks in what should be the wealthiest state in the country.”

Expanding Health Coverage

Newsom did not include money in his proposed budget to expand Medi-Cal to unauthorized immigrants age 65 and older. He had previously promised to fund the proposal, estimated to cost $350 million per year once fully implemented, but he said Friday the state cannot afford to commit to ongoing costs with a projected budget deficit starting in fiscal year 2022-23. California already offers full Medicaid benefits for income-eligible unauthorized immigrants up to age 26.

Some lawmakers and health care advocates countered that providing health insurance for undocumented immigrants would save lives and reduce costs, especially during the pandemic, and vowed to continue to fight for the expansion.

“To say we are disappointed is describing it very lightly,” said Orville Thomas, a lobbyist with the California Immigrant Policy Center. “These are Californians dying and getting sick at disproportionate rates during covid.”

CMS Wants To Force Insurers To Ease Prior Authorization

hhs

Source: Modern Healthcare, by Michael Brady

The Trump administration on Thursday proposed changes that aim to improve patient and provider access to medical records and reform prior authorization.

The proposed rule would require payers—including Medicaid, the Children’s Health Insurance Program and exchange plans—to build application program interfaces to support data exchange and prior authorization. According to CMS, the changes would allow providers to know in advance what documentation each payer would require, streamline documentation processes and make it easier for providers to send and receive prior authorization information requests and responses electronically.

“Prior authorization is a necessary and important tool for payors to ensure program integrity, but there is a better way to make the process work more efficiently to ensure that care is not delayed and we are not increasing administrative costs for the whole system,” CMS Administrator Seema Verma said in a statement.

According to CMS, the plan builds on the interoperability regulations approved by the agency in May.

“These policies, taken together, could lead to fewer prior authorization denials and appeals while improving communication and understanding between payers, providers and patients,” the agency said in a statement.

Comments on the proposed rule close Jan. 4. The agency wants it to take effect on Jan. 1, 2023.

Under the proposal, payers would have to build and maintain application program interfaces using the Health Level 7 Fast Healthcare Interoperability Resources—FHIR—standard.

It would also reduce the time insurers have to inform providers about prior authorization decisions. Payers would have 72 hours to respond to urgent prior authorization requests—except for plans sold on federally-run exchanges—and seven days for non-urgent requests.

“Payers would also be required to provide a specific reason for any denial, which will allow providers some transparency into the process. To promote accountability for plans, the rule also requires them to make public certain metrics that demonstrate how many procedures they are authorizing,” CMS said in a statement.

The agency is considering a similar proposal for Medicare Advantage plans.

Application programming interfaces allow electronic health records and other information systems to talk to each other or third-party applications. They’ve been a key part of the Trump administration’s effort to make it easier for providers, insurers and patients to share health-related information. But key players in the healthcare industry have resisted adoption because of privacy and implementation concerns.

Medicare Part B Premiums To Rise 2.7% In 2021, With Premiums For Highest-Income Couples Topping $12,000 A Year

When you're saving for retirement, keep in mind that Medicare premiums include surcharges for high-income earners.

Source: Forbes, by Ashlea Ebeling

The Centers for Medicare & Medicaid Services has announced Medicare Part B premiums for 2021, and the base premium increases just 2.7% from $144.60 a month to $148.50 a month. That $3.90 monthly increase compares to a big $9.10 monthly increase last year, after a $1.50 monthly increase the year before. Meanwhile high earners are still getting used to income-related surcharges that kicked into higher gear in 2018, and those have been bumped up again too. The wealthiest senior couples will be paying more than $12,000 a year in Medicare Part B premiums. Part B (the base and the surcharge) covers doctors’ and outpatient services.

The annual deductible for all Medicare Part B beneficiaries is $203 in 2021, an increase of just $5 from the annual deductible of $198 in 2020. What kept the increases n the Part B premiums and the deductible in check this year? As part of the short-term budget bill in October, Congress capped the increases. Yet Medicare spending is expected to grow this year as people seek care they may have delayed due to Covid-19, CMS says.

The CMS announcement comes after last month’s Social Security Administration’s COLA announcement: a 1.3% cost of living adjustment for 2021. The average Social Security benefit for a retired worker will rise by $20 a month to $1,543 in 2021, while the average benefit for a retired couple will grow $33 a month to $2,596. The higher Medicare Part B premium cuts into retirees’ monthly Social Security payments. Part B premiums typically are deducted from monthly Social Security checks.

While most of the 60 million Medicare recipients will pay the new $148.50 standard monthly premium, some will pay less because of a “hold harmless” provision that limits certain beneficiaries’ increase in their Part B premium to be no greater than the increase in their Social Security benefits.

CMS says 7% of Medicare recipients will have to pay income-related surcharges. The graduated surcharges for high-income seniors kick in for singles with modified adjusted gross income of more than $88,000 and for couples with a MAGI of more than $176,000. An individual earning more than $88,000, but less than or equal to $111,000, will pay $207.90 in total a month for Part B premiums in 2021, including a $59.40 surcharge. That’s up 2.7% from 2020, when they paid $202.4 total in a month, including a $57 surcharge.

By comparison, the wealthiest retirees—singles with $500,000 of income or more and couples with $750,000 of income or more—will face total premiums of $504.90 a month per person, including a $356.40 surcharge, in 2020. That comes to $12,117.60 a year f0r a couple.

The income-related premium surcharges apply to Part D premiums for drug coverage too.

CMS announced in July that the average basic premium for Part D, private health plans which cover prescription drugs, is $30.50 for 2021, down 12% from 2017. But it’s still important to shop around for a plan. Even as Part D premiums fall, there may be higher costs elsewhere, such as higher co-pays, narrower formularies, or a drug may not be covered altogether, says Mary Johnson, Social Security and Medicare policy analyst with The Senior Citizens League. The State Health Insurance Programs National Network lists places where you can get free help locally to compare plans. Medicare open enrollment runs from October 15, 2020 through December 7, 2020 for the 2021 plan year.

Insurers Slam CMS Proposal To Hasten Medicare Coverage Of Breakthrough Medical Devices

Insurers slam CMS proposal to hasten Medicare coverage of breakthrough  medical devices | FierceHealthcare

Source: Fierce Healthcare, by Robert King

A major insurance group blasted a proposed rule intended to grant faster Medicare coverage decisions on new breakthrough medical devices, saying the rule could lead to unsafe devices reaching seniors.

The rule, proposed by the Centers for Medicare & Medicaid Services (CMS) back in September, aims to address a lag time from when the Food and Drug Administration (FDA) approves a device and when CMS delivers a national coverage determination (NCD) that would determine whether Medicare covers it.

But America’s Health Insurance Plans (AHIP), the top insurance lobbying group, said there is a vital reason for that lag time.

The proposed pathway could result in a “less rigorous evidence-based coverage process and potentially result in premature coverage of unproven devices for the Medicare population,” AHIP said in comments on the rule. The comment period closed Monday.

The new pathway would only apply to devices that are cleared through the agency’s 510(k) pathway and have a breakthrough designation, which applies to devices that provide a better treatment for life-threatening or debilitating diseases. Under the 510(k) pathway, a device only needs to prove it is similar to another device on the market and bypasses more rigorous clinical studies.

Normally, it takes CMS nine to 12 months to finalize an NCD on a device after it clears the FDA.

AHIP commented that after a medical device is approved by the FDA, a plan’s medical policy committee evaluates its safety and efficacy.

“Absent an NCD, health insurance providers use evidence-based guidelines to develop medical coverage policies,” AHIP said.

However, the proposed pathway would act instead as an “interim NCD” with a less rigorous coverage process, the group commented.

AHIP was also concerned that the 510(k) pathway has sometimes been used to clear medical devices to enter the market without comprehensive safety evaluations.

If CMS decides to continue with the pathway in a final rule, AHIP wants the agency to add a process for stakeholders to evaluate the device for safety, efficacy and value before a Medicare coverage determination is made.

The Medicare Payment Advisory Commission (MedPAC), a panel that advises Congress and CMS on Medicare coverage issues, was also concerned about using the FDA’s approval process to determine Medicare coverage.

“The FDA’s role in the drug and device development process as a regulator is distinct and separate from the role of CMS as a payer,” the panel said in comments on the rule.

The panel said the FDA looks at whether a device is safe and effective for its intended use but may or may not include whether that device is safe for the Medicare population.

CMS should, at the very least, include a coverage with evidence development policy that would still gather clinical evidence on the device, MedPAC said.

The panel was also concerned with CMS’ decision to modify the definitions of “reasonable and necessary” in coverage determinations. Federal law requires Medicare Part A and B to cover items and services that are “reasonable and necessary” for diagnosis or treatment.

Factors used to make this determination include whether the device is safe and effective and is not experimental or investigational.

However, the proposed rule said that commercial insurance coverage could be used to meet the “reasonable and necessary” standard.

But relying on commercial coverage policies could result in coverage of services that don’t improve the outcomes for Medicare patients, MedPAC warns.

“The proposal circumvents Medicare’s coverage determination processes and could undermine Medicare’s evidentiary standard,” the panel added.

AHIP said CMS should not make any decisions based on how a single commercial plan covers a device.

“Coverage by a majority of health insurance providers or a majority of commercial enrollees would be more representative,” AHIP said.

The medical device industry also has concerns with the rule’s proposed definitions.

“Commercial insurance coverage decisions lack transparency and processes for stakeholder engagement and are not appropriate for inclusion in Medicare’s reasonable and necessary definition,” said the Advanced Medical Technology Association (AdvaMed), the leading device lobbying group, in comments.

However, AdvaMed cheered the moves to hasten coverage determination for breakthrough devices.

“CMS is sending a signal to the entire innovation ecosystem that taking the risk to develop new breakthroughs will be rewarded if those devices receive FDA marketing authorization and improve patient care,” the group said.

CMS Finalizes Price Transparency Rule Aimed At Health Plans

CMS finalizes price transparency rule aimed at health plans | BenefitsPRO

Source: BenefitsPRO, by Emily Payne

The Trump administration has taken the drive for health care price transparency a step further with the finalization of a new rule that will require health insurers and self-insured health plans to share details on pricing and cost-sharing.

The Transparency in Coverage rule builds on another highly publicized rule that will require hospitals to post their prices starting in January. Under the new rule, insurers and employer-sponsored health plans will be required to post in-network and out-of-network negotiated rates, “including an estimate of the individual’s cost-sharing liability for covered items or services furnished by a particular provider,” according to the rule. Grandfathered health plans will be exempt.

“President Trump is solving longstanding problems in our health care system; hidden health care prices have produced a dysfunctional system that serves special interests but leaves patients out in the cold,” CMS Administrator Seema Verma said in a statement. “Price transparency puts patients in control and forces competition on the basis of cost and quality, which can rein in the high cost of care. CMS’ action represents perhaps the most consequential health care reform in the last several decades.”

The new rule would go into effect on or after January 1, 2023, giving health insurers plenty of time to prepare for the list of requirements (or challenge it in the courts). The list includes creating online tools to help consumers understand out-of-pocket costs and negotiated rates for 500 “shoppable services,” expanding the list every year thereafter.

Healthcare Bluebook, whose experts were an active part of the policymaking, applauds the new rule. ” We believe this is an important win for consumers and employers and will help deliver a clearer picture of health care costs to support better decision making,” the company said in a statement. “ Our teams are already documenting potential additional requirements for our platform and developing a cost schedule and cost model.”

The news was also met with accolades from ERIC, the advocacy arm of ERISA. “The regulation comes not a minute too soon, as millions of Americans are struggling to pay inflated health care costs. Price transparency will empower patients to make more informed decisions while also driving competition among health care providers, reducing health care costs, and improving the quality of care,” James Gelfand, senior vice president of health policy, said in a statement.

According to the CMS, ” For the first time, most consumers will be able to get real-time and accurate estimates of their cost-sharing liability for health care items and services from different providers in real time, allowing them to both understand how costs for covered health care items and services are determined by their plan, and also shop and compare health care costs before receiving care.”

The rule also calls upon insurers to offer three different machine-readable files, addressing “ in-network provider negotiated rates, historical out-of-network allowed amounts, and drug pricing information.”

The rule also includes some good news for insurers: those who reward consumers for selecting lower-cost, higher-value providers will be allowed to deduct the amount of the savings passed on to the consumer when calculating their medical loss ratios,

Last Updated 02/24/2021

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