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Medicare and Medicaid

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U.S. Health Care Coverage and Spending, 2017
"Private health insurance spending, as a percentage of all health consumption expenditures, has increased by about 12 percentage points since 1960. This growth is partially due to increases in enrollment and, when considered alongside the implementation and expansions of Medicare and Medicaid, corresponds with the drop in out-of-pocket spending since 1960." (Congressional Research Service [CRS])
Medicare Won't Pay For Your Annual Physical, Just A 'Wellness Visit'
"An annual physical typically involves an exam by a doctor along with bloodwork or other tests. The annual wellness visit generally doesn't include a physical exam, except to check routine measurements such as height, weight and blood pressure. The focus of the Medicare wellness visit is on preventing disease and disability by coming up with a 'personalized prevention plan' for future medical issues based on the beneficiary's health and risk factors." (Kaiser Health News)
HHS Proposes Changes to Rebates for Part D Plans Under the Anti-Kickback Statute
"HHS has requested feedback on many aspects of the proposals such as ... the impact upon beneficiary access to prescription pharmaceutical products either due to cost or formulary placement.... If enacted, the proposals will likely lead to an increase in the Part D premiums as it will substantially alter the relationship between pharmaceutical manufacturers, Medicare Part D plans, PBMs, and participants. The new relationship could also extend to or impact those in the non-Medicare, i.e., commercial, marketplace." (Cheiron)
Americans Cite Healthcare Expenses as No. 1 Barrier to Early Retirement
"When asked to name barriers to financial independence and early retirement, Americans are less concerned about uncertain market conditions (37 percent) or inflation (35 percent), than they are about healthcare costs (57 percent)... An overwhelming majority of Americans (76 percent) point to Medicare as the best way to pay for healthcare in retirement. Yet more than half of pre-retirees (61 percent) are not confident that it will cover the bulk of their retirement medical expenses." (TD Ameritrade)
'Medicare-For-All' Bill Introduced in the House -- Why Does It Matter?
"[T]he transition to the new Medicare-for-all system would take place over two years ... This House vision of Medicare-for-all would also cover long-term care.... The House bill also would take a swipe at high prices for prescription drugs by empowering the government to negotiate prices directly with manufacturers and to take away and reissue drug patents if such efforts faltered." (Kaiser Health News)
Congress Mulls Cap on What Medicare Enrollees Pay for Drugs
"The effort to cap out-of-pocket costs in Medicare's prescription plan is being considered as part of broader legislation to restrain drug prices. Limits on high medical and drug bills are already part of most employer-based and private insurance. They're called 'out-of-pocket maximums' and are required under the Obama-era health law for in-network services. But Medicare has remained an outlier even as prices have soared for potent new brand-name drugs, as well as older mainstays such as insulin." (Associated Press)
'Pathways to Success' MSSP Final Rule: Financial Benchmark
"On December 31, 2018, [CMS] published a final rule that ... includes changes to the financial benchmark methodology that measures the gross savings or losses of an accountable care organization (ACO) under the [Medicare Shared Savings Program]. Four key elements of the financial benchmark methodology changed: agreement period length, regional fee-for-service (FFS) adjustment, risk adjustment, and trend." (Milliman)
74 Medicare ACOs Depart
"The departures of 13 percent of Medicare' ACOs left 487 in the program in 2019... [A] total of 59 MSSP ACOs dropped out of the program in 2016 and 2017... 26 percent of ACOs that reached the end of their three-year agreement opted to not renew their agreement at the end of 2018." (Healthcare Financial Management Association [HFMA])
Medicare Part D Disclosures Due by March 1 for Calendar Year Plans (PDF)
"Employers with health plans that provide prescription drug coverage to individuals who are eligible for Medicare Part D are subject to certain disclosure requirements. Plan sponsors must complete an online disclosure form with CMS within 60 days after the start of the plan year, or March 1, 2019, for calendar year plans." (Cowden Associates, Inc.)
[Guidance Overview] HHS OIG Proposes Anti-Kickback Safe Harbor Amendments to Regulate and Restrict the Provision of Manufacturer Remuneration to Plan Sponsors and PBMs
"As rebates paid by pharmaceutical manufacturers to health plan sponsors and PBMs are a central feature of the U.S. drug distribution and reimbursement system, the Proposed Rule represents a groundbreaking reform measure that could dramatically impact consumers and supply chain stakeholders. If finalized, the Proposed Rule would go into effect on January 1, 2020." (Epstein Becker Green)
[Guidance Overview] HHS Proposes New Rules to Eliminate Drug Rebates and Encourage Direct Discounts
"The proposed rule has the potential to cause significant disruption to the status quo of the drug supply chain. PBMs interact and affect all stakeholders throughout the prescription drug supply chain and markets, including prescription drug benefit plans ... pharmaceutical manufacturers and pharmacies." (Foley & Lardner LLP)
[Guidance Overview] HHS Proposes Rule Challenging Drug Manufacturer Rebates to PBMs and Payors
"The Proposed Rule would make explicit that the AKS discount safe harbor does not protect manufacturer rebates on prescription drugs paid to Medicare Part D plan sponsors, Medicaid managed care organizations (MCOs), or pharmacy benefit managers (PBMs) in the context of these government programs. The Proposed Rule would create new safe harbors for certain point-of-sale price reductions on prescription drugs and for certain PBM service fees paid by manufacturers." (King & Spalding)
[Guidance Overview] Administration Releases Long-Awaited Drug Rebate Proposal
"[T]he proposed rule envisions two new safe harbors: one for rebates which are passed on to the patient at the point of sale, and another for flat service fee payments made to PBMs, which could not be tied to the list prices of drugs." (Rachel Sachs, in Health Affairs)
Winners and Losers Under HHS Plan to Slash Drug Rebate Deals
"Consumers are unlikely to collect the full benefit of eliminated rebates. At the same time, the change would produce uncertain ricochets, including higher drug-plan premiums for consumers, that would produce new winners and losers across the economy.... Possible Winners: Chronically ill patients who take lots of expensive medicine ... Drug companies ... Possible Losers: Pharmacy benefit managers ... Insurance companies ... Patients without chronic conditions and high drug costs." (Kaiser Health News)
Estimates of the Impact of Eliminating Rebates for Reduced List Prices at Point-of-Sale for the Part D Program (PDF)
10 pages. "[T]he average beneficiary would have a premium increase of about 8%, and average beneficiary cost sharing would be reduced by about 9.5%.... [T]he net effect for beneficiaries is a 2% reduction in out-of-pocket expenses.... [A]pproximately 30% of non-low income beneficiaries will see a net savings ... [T]he other 70% of non-low income beneficiaries will on average experience a net increase in out of pocket expenses.... [T]he drug spend level threshold at which the non-low income beneficiary begins to experience a net savings will occur at an annual spend of $2,200 to $2,500." (Wakely Consulting Group, for Assistant Secretary for Planning and Evaluation [ASPE], U.S. Department of Health and Human Services [HHS])
[Official Guidance] Text of HHS Proposed Regs: Removal of Safe Harbor Protection for Rebates Involving Prescription Pharmaceuticals and Creation of New Safe Harbor Protection for Certain Point-of-Sale Reductions in Price on Prescription Pharmaceuticals and Certain PBM Fees
123 pages. "The amendment would revise the discount safe harbor to explicitly exclude from the definition of a discount eligible for safe harbor protection certain reductions in price or other remuneration from a manufacturer of prescription pharmaceutical products to plan sponsors under Medicare Part D, Medicaid managed care organizations ... or pharmacy benefit managers (PBMs) under contract with them. In addition, the Department is proposing two new safe harbors. The first would protect certain point-of-sale reductions in price on prescription pharmaceutical products, and the second would protect certain PBM service fees." (Office of Inspector General, U.S. Department of Health and Human Services [HHS])
Essential Facts About Medicare and Prescription Drug Spending
"[1] Medicare's share of the nation's retail prescription drug spending has increased from 18% in 2006 to 30% in 2017.... [2] Prescription drugs covered under both Part B and Part D accounted for 19% of all Medicare spending in 2016.... [3] Ten drugs accounted for 17% of all Part D spending in 2016 ... [4] Prescription drugs accounted for $1 in every $5 that Medicare beneficiaries spent out-of-pocket on health care services in 2016, not including premiums." (Henry J. Kaiser Family Foundation)
Calendar Year Health Plans Must Complete Online CMS Disclosure by March 1, 2019
"The plan sponsor must complete the disclosure within 60 days after the beginning of the plan year. Sponsors of insured plans may choose to file within 60 days after the beginning of the insurance contract year, but whatever approach is adopted, it should be used consistently.... A CMS filing is also required within 30 days of termination of a prescription drug plan and for any change in a plan's creditable coverage status." (Lockton)
Enhancing Work Incentives for Older Workers: Social Security and Medicare Proposals to Reduce Work Disincentives (PDF)
24 pages. "[The authors consider three proposals:] ... [1] eliminating the earnings test for participants between age 62, the early retirement age (ERA), and the full retirement age (FRA) ... [2] creating a paid-up status for Social Security, a point at which employees and employers would no longer be required to pay the payroll tax and earnings would not alter future benefits.... [3] a paid-up status for Medicare, coupled with a policy shift for Medicare that would return the program to its original status as the primary payer for covered expenditures rather than its current status as the secondary payer." (Robert L. Clark and John B. Shoven, for The Brookings Institution)
Medicare Expands Value Pay in MA and Part D Plans
"The voluntary expansion will be open to MA plans, Regional Preferred Provider Organizations, and all special-needs plans.... The new VBID models will focus on one or more of the following: [1] Condition- or socioeconomic-based designs; [2] Rewards and incentives programs; [3] Telehealth networks; [4] Wellness and healthcare planning." (Healthcare Financial Management Association [HFMA])
GAO Report: Medicare -- Voluntary and Mandatory Episode-Based Payment Models and Their Participants
"GAO was asked to review the episode-based payment models developed by CMS. This report [1] describes the characteristics of the providers that participated in these models and [2] compares the relative advantages of voluntary versus mandatory episode-based payment models, as identified by stakeholders." [GAO-19-156, published Dec. 21, 2018, released Jan. 22, 2019] (U.S. Government Accountability Office [GAO])
[Guidance Overview] CMS Announces New Model to Lower Drug Prices in Medicare Part D and Transformative Updates to Existing Model for Medicare Advantage
"Under the new model, which takes effect for the 2020 plan year, participating plans will take on greater risk for spending in the catastrophic phase of Part D, creating new incentives for plans, patients, and providers to choose drugs with lower list prices. Based on plan year performance, CMS will calculate a spending target for what governmental spending would have been without plans taking on this additional risk. Participating Part D plans will share in savings if they stay below the target but will be accountable for losses if they exceed the target. For the first time, the model also introduces a Part D rewards and incentives program to align this model with the changes to VBID, and to provide Part D plans with additional tools to control drug costs and help enrollees in choosing drugs with lower list prices." (Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS])
[Guidance Overview] Text of CMS Value-Based Insurance Design Model (VBID) Fact Sheet CY 2020
"For the CY 2020 VBID application period, which is open now through March 1, 2019, eligible Medicare Advantage organizations may apply to test one or more of the following new interventions: [1] Value-Based Insurance Design by Condition, Socioeconomic Status, or both ... [2] Medicare Advantage and Part D Rewards and Incentives Programs ... [3] Telehealth Networks ... [4] Wellness and Health Care Planning." (Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS])
HHS Medicare Drug Shift Plan Could Reduce Costs Overall But Raise Them for Some
"At 2018 prices, Part B spending for the 75 brand-name drugs with the highest Part B expenditures was estimated to be $21.6 billion annually. Under the proposed policy, total Part D drug spending for these drugs would fall to an estimate in the range of $17.6 billion and $20.1 billion after rebates, corresponding to a 6.9% to 18.3% decrease in drug spending in Part D compared with Part B costs." (American Journal of Managed Care)
[Opinion] High Prices Drive High Health Care Spending in the U.S., But So Too Do Other Factors
"[T]he prices that US providers negotiate with insurers are aberrantly high and that the level of providers' commercial prices differentially raises health spending in the US compared to other nations. However, it is crucial to note that the regulated prices US providers are paid by the Medicare and Medicaid program are not hugely out of sync with the regulated prices set in other countries." (Health Affairs)
ACOs Should Plan for Shorter Path to Greater Risk in CMS' Overhauled Medicare Shared Savings Program
"In an analysis of Medicare data for 560 [Medicare Shared Savings Program (MSSP)] ACOs to estimate where they would fall in CMS' new two-prong model, two out of three ACOs had the shorter window before they would be expected to take on greater risk." (FierceHealthcare)
CMS Releases 2016 Public Use File for the Medicare Current Beneficiary Survey (MCBS)
"The MCBS 2016 public use file (MCBS PUF) provides a publicly available MCBS file for researchers interested in the health, health care use, access to and satisfaction with care for Medicare beneficiaries, while providing the very highest degree of protection to the Medicare beneficiaries' protected health information.... The MCBS PUF is prepared from data collected in 2016 from 12,852 community dwelling Medicare beneficiaries representing a population of 53 million and contains standard demographic variables, such as age categories, race/ethnicity and gender, as well as information about health conditions, access to and satisfaction with care, type of insurance coverage, and information on utilization, such as the number of fee-for-service claims per beneficiary for certain health care event types." (Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS])
[Guidance Overview] CMS Finalizes Proposed Redesign to Medicare Shared Savings Program
"Low-revenue ACOs are permitted to stay in one-sided risk-sharing models for a longer period ... Any ACO determined to be experienced with Risk Models however, is required to take on risk immediately.... CMS is also cutting the shared savings rate that will be available for ACOs until they enter a Risk Model.... CMS finalized modifications to its calculation of the regional adjustment to an ACO's performance benchmark[.]" (K&L Gates)
[Guidance Overview] 'Pathways to Success' Update: CMS Issues Final Rule on Changes to the ACO Program
"On December 21, 2018, CMS issued the final rule for the redesign of the [Medicare Shared Savings Program (MSSP) which] includes the following: [1] Greater savings for one-sided risk models.... [2] Qualification as a low revenue ACO.... [3] Additional year of one-sided risk for new low revenue ACOs.... [4] High revenue ACO participation in BASIC Track Level E.... [5] Repayment mechanism for two-sided risk.... [6] Benchmarking methodology." (Sheppard Mullin)
2015 Medicare Current Beneficiary Survey Annual Chartbook and Slides
The MCBS 2015 Chart Book is now updated to include two new sections with information on the use and cost of health care services reported by survey beneficiaries. This release will supplement the information in Version 1 of the MCBS 2015 Chart Book which included information on beneficiaries' satisfaction with care, usual source of care, functional status, and health and well-being. (Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS])
[Guidance Overview] Pathways to Success: An Overhaul of Medicare's ACO Program
"The rule is projected to achieve $2.9 billion in savings over ten years.... One key element of [this final rule] is a reduction in the amount of time that an ACO can remain in the program without taking accountability for healthcare spending.... [The] rule also increases flexibility for certain performance-based risk ACOs to encourage innovation and expand access to high-quality services that are convenient for patients, including telehealth services provided at a patient's place of residence." (Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS])
[Official Guidance] Text of CMS Final Regs: Medicare Shared Savings Program; Accountable Care Organizations Pathways to Success and Extreme and Uncontrollable Circumstances Policies for Performance Year 2017
957 pages. "The policies included in this final rule provide a new direction for the Shared Savings Program by establishing pathways to success through redesigning the participation options available under the program to encourage ACOs to transition to two-sided models (in which they may share in savings and are accountable for repaying shared losses). These policies are designed to increase savings for the Trust Funds and mitigate losses, reduce gaming opportunities, and promote regulatory flexibility and free-market principles. This final rule also provides new tools to support coordination of care across settings and strengthen beneficiary engagement; and ensure rigorous benchmarking." (Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS])
Are Medicare Part D Disclosure Notices Required for an HRA or Health FSA?
"The answer is probably yes for the HRA, and no for the health FSA. This assumes that your company's health FSA and HRA will offer prescription drug coverage to Part D-eligible individuals -- i.e., individuals covered under Medicare Part A or Part B, including active and disabled employees, COBRA participants, retirees, and their covered spouses and dependents who live in the service area of a Part D prescription drug plan." (Thomson Reuters / EBIA)
CMS Office of the Actuary Releases 2017 National Health Expenditures
"Hospital spending (33 percent of total healthcare spending) decelerated in 2017, growing 4.6 percent to $1.1 trillion compared to 5.6 percent growth in 2016.... Physician and clinical services spending (20 percent of total healthcare spending) increased 4.2 percent to $694.3 billion in 2017.... Retail prescription drug spending (10 percent of total healthcare spending) slowed in 2017, increasing 0.4 percent to $333.4 billion.... The 3.9 percent growth in healthcare spending was slightly slower than growth in the overall economy (4.2 percent) in 2017." (Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS])
Modernizing Part D and Medicare Advantage to Lower Drug Prices and Reduce Out-of-Pocket Expenses: Highlights from the Proposed Rule
"Plan sponsors should review the proposed regulation and consider submitting comments to CMS (the comment deadline is January 25, 2019).... [T]he proposed rule raises operational questions that will need to be addressed by plan sponsors and PBMs. There will be pricing implications in the bids, and other actuarial considerations such as trend and Part D risk corridor projections.... [T]he provisions are likely to necessitate re-negotiation of contracts between plan sponsors and pharmacy benefit managers." (Wakely Consulting Group)
[Guidance Overview] CMS Releases Medicare Advantage and Part D Drug Pricing Proposed Rule for Contract Year 2020
"The agency has proposed five changes to amend Medicare Advantage and Medicare Prescription Drug Benefit (Part D) regulations to support health and drug plans' negotiation for lower drug prices and to reduce out-of-pocket costs for MA and Part D enrollees.... [1] Providing plan flexibility to manage protected classes ... [2] E-prescribing and the Part D prescription drug program; updating Part D e-prescribing standards ... [3] Medicare Advantage and step therapy for Part B drugs ... [4] Pharmacy price concessions to drug prices at the point of sale ... [5] Part D explanation of benefits." (Epstein Becker Green)
Economic Analysis of 'Medicare for All'
"As of 2017, the U.S. was spending about $3.24 trillion on personal health care -- about 17 percent of total U.S. GDP. Meanwhile, 9 percent of U.S. residents have no insurance and 26 percent are underinsured -- they are unable to access needed care because of prohibitively high costs. Other high-income countries spend an average of about 40 percent less per person and produce better health outcomes. Medicare for All could reduce total health care spending in the U.S. by nearly 10 percent, to $2.93 trillion, while creating stable access to good care for all U.S. residents." (Political Economy Research Institute, University of Massachusetts Amherst [PERI])
When Is Medicare Entitlement a COBRA Qualifying Event?
"If a COBRA triggering event, such as Medicare entitlement, does not cause loss of coverage under your plan, there is no qualifying event, and COBRA need not be offered.... [T]he Medicare Secondary Payer (MSP) rules generally prohibit group health plans from making Medicare entitlement an event that causes a loss of coverage for active employees." (Thomson Reuters / EBIA)
[Guidance Overview] CMS Issues Proposed Rule on Modernizing Part D and Medicare Advantage to Lower Drug Prices and Reduce Out-of-Pocket Expenses
"Key provisions of the Proposed Rule are ... [1] Providing plan flexibility to manage Part D protected classes ... [2] Prohibition on gag clauses in pharmacy contracts ... [3] E-prescribing and the Part D prescription drug program: updating Part D e-prescribing standards ... [4] Part D explanation of benefits ... [5] Medicare advantage and step therapy for Part B drugs ... [6] Pharmacy price concessions in negotiated price." (Sheppard Mullin)
[Guidance Overview] Administration Proposes Strategies to Lower Pharmaceutical Prices in Medicare Part D
"As set out in the proposed rule, the plan has three major new provisions: [1] providing Part D plans with more flexibility to manage protected classes, [2] updating existing e-prescribing systems to make patients' costs visible when a prescription is ordered, and [3] requiring pharmacy price concessions for drugs at the point of sale." (Health Affairs)
[Official Guidance] New CMS Online Tool Displays Cost Differences for Certain Surgical Procedures
"The Procedure Price Lookup tool displays national averages for the amount Medicare pays the hospital or ambulatory surgical center and the national average copayment amount a beneficiary with no Medicare supplemental insurance would pay the provider." (Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS])
CMS Takes Action to Lower Prescription Drug Costs by Modernizing Medicare
"The proposal would ensure that Medicare Advantage and Part D plans have more tools to negotiate lower drug prices, and the agency is also considering a policy that would require pharmacy rebates to be passed on to seniors to lower their drug costs at the pharmacy counter.... CMS is also considering for a future plan year, which may be as early as 2020, a policy that would ensure that enrollees pay the lowest cost for the prescription drugs they pick up at a pharmacy, after taking into account back-end payments from pharmacies to plans." (Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS])
[Guidance Overview] Text of CMS Fact Sheet: Contract Year 2020 Medicare Advantage and Part D Drug Pricing Proposed Rule
"CMS is proposing or outlining for consideration by stakeholders a number of provisions that implement these four strategies. [1] Providing plan flexibility to manage protected classes.... [2] E-prescribing and the Part D prescription drug program ... [3] Medicare advantage and step therapy for Part B drugs ... [4] Part D explanation of benefits ... [5] Prohibition against gag clauses in pharmacy contracts ... [6] Pharmacy price concessions in the negotiated price." (Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS])
[Official Guidance] Text of CMS Proposed Regs: Modernizing Part D and Medicare Advantage to Lower Drug Prices and Reduce Out of Pocket Expenses
185 pages. "This proposed rule would amend the Medicare Advantage (MA) program (Part C) regulations and Prescription Drug Benefit program (Part D) regulations to support health and drug plans' negotiation for lower drug prices and reduce out-of-pocket costs for Part C and D enrollees." (Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS])
Big Change Ahead for Medicare -- and Employers Will Feel It, Too
"The Trump Administration is considering a proposal that is a major shake-up in the way Medicare reimburses for infused drugs paid under Medicare Part B, which ... could have a major ripple effect on employer plans.... In the Medicare program today, ... [p]hysicians are reimbursed the cost of the drug plus an add-on fee--typically 6% of the drug's cost.... Simply stated, if physicians and/or pharma companies make less money off these products they will look to replace that revenue. And that will very likely result in massive cost shifting to the private sector." (Mercer)
[Guidance Overview] Drug Pricing Plan Would Tie Medicare Part B Reimbursement to International Prices
"[The International Pricing Index (IPI) Model] would: [1] Pay a new IPI Model vendor directly for Part B drugs at a benchmarked international price. [2] Pay physicians and hospitals a per-month or per-dispense administration fee, which ... would not be tied in any direct manner to the cost of the drug administered.... [O]ne of the primary effects of the IPI Model would be to remove health systems and hospitals from billing for certain Part B drugs altogether." (K&L Gates)
[Guidance Overview] CMS Proposes to Modernize Medicare Advantage, Expand Telehealth Access for Patients
"[T]he proposed changes would remove barriers and allow Medicare Advantage plans to offer 'additional telehealth benefits' not otherwise available in Medicare to enrollees, starting in plan year 2020 as part of the government-funded 'basic benefits.' " (Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS])
Trump Administration Outlines Plan to Lower Pharmaceutical Prices in Medicare Part B
"The plan contains three key elements: substituting private-sector pharmaceutical vendors for the current Part B 'buy and bill' practice, changing the Part B Average Sales Price plus 6 percent reimbursement system to a flat fee, and implementing international reference pricing. The first two of these were attempted -- and failed -- in previous administrations." (Health Affairs)
[Guidance Overview] CMS Proposes International Pricing Index Model for Medicare Part B Drugs
"CMS is considering issuing a proposed rule in the spring of 2019 on the potential model, called the International Pricing Index (IPI) Model. The potential IPI Model would start in spring 2020 and operate for five years, until the spring of 2025. Over the course of the model, CMS would monitor and evaluate the impact of the model on beneficiary access to drugs, program costs, and the quality of care for beneficiaries.... CMS is seeking feedback on the potential parameters of the IPI Model." (Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS])
[Official Guidance] Text of CMS Notice of Proposed Rulemaking: International Pricing Index Model for Medicare Part B Drugs
59 pages. "CMS intends to test whether [1] phasing down the Medicare payment amount for selected Part B drugs to more closely align with international prices; [2] allowing private-sector vendors to negotiate prices for drugs, take title to drugs, and compete for physician and hospital business; and [3] changing the 4.3 percent (post-sequester) drug add-on payment in the model to reflect 6 percent of historical drug costs translated into a set payment amount, would lead to higher quality of care for beneficiaries and reduced expenditures to the Medicare program." (Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS])
Some Couples Could Need as Much as $400,000 to Cover Medicare Expenses (PDF)
"In 2018, a 65-year-old man needs $75,000 in savings and a 65-year-old woman needs $99,000 for a 50 percent chance of having enough to cover premiums and median prescription drug expenses in retirement.... For a 50 percent chance of having enough to cover health care expenses in retirement, a couple with median prescription drug expenses needs $174,000 in savings. For a 90 percent chance of having enough, the couple need s $296,000 in savings. At the extreme -- a couple with drug expenses at the 90th percentile throughout retirement who want a 90 percent chance of having enough money for health care expenses in retirement by age 65 -- targeted savings are $399,000 in 2018." (Employee Benefit Research Institute [EBRI])
[Opinion] Consumer-Facing Medicare Plan Tools Are Inaccessible and Inaccurate
"Few would probably describe shopping for health insurance as 'fun,' but research shows Medicare Plan Finder (MPF), the federal government's website for finding information about plan options, makes this process particularly unbearable.... One of MPF's biggest problems? Information about out-of-pocket costs is difficult to find and understand. On top of that, this information doesn't account for an individual's health conditions, physician visits per year, and other factors that impact costs." (FierceHealthcare)
[Guidance Overview] HHS Fact Sheet: What You Need to Know about Putting Drug Prices in TV Ads
"The 10 most commonly advertised drugs have list prices ranging from $535 to $11,000 per month or usual course of therapy.... 47 percent of Americans have high-deductible health plans, under which they often pay the list price of a drug until their insurance kicks in.... List prices are also what patients pay if a drug is not on their insurance formulary, and list prices help determine insurance plans' placement of drugs on their formulary." (U.S. Department of Health and Human Services [HHS])
[Guidance Overview] CMS Proposes Requirement that Manufacturers Disclose Drug Prices in Television Ads
"[T]he posting would take the form of a legible textual statement at the end of the ad. The HHS Secretary would maintain a public list of drugs that were advertised in violation of this rule. CMS would provide an exception to the requirement to post prices for prescription drugs with list prices of less than $35 per month." (Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS])
[Official Guidance] Text of CMS Proposed Regs: Medicare and Medicaid Programs -- Drug Pricing Transparency
45 pages. "This proposed rule would ... [amend] the Medicare Parts A, B, C and D programs, as well as the Medicaid program, to require direct-to-consumer (DTC) television advertisements of prescription drugs and biological products for which payment is available through or under Medicare or Medicaid to include the Wholesale Acquisition Cost (WAC, or 'list price') of that drug or biological product.... [CMS seeks] comment on [1] [W]hether Wholesale Acquisition Cost is the amount that best reflects the 'list price' for the stated purposes of price transparency and comparison shopping under this proposed regulation.... [2] [W]hether 30-day supply and typical course of treatment are appropriate metrics for a consumer to gauge the cost of the drug.... [3] [H]ow to treat an advertised drug that must be used in combination with another non-advertised drug or device.... [4] [W]hether the cost threshold of $35 to be exempt from compliance with this rule is the appropriate level and metric for such an exemption." (Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS])
The Impact of Insurance Expansions on the Already Insured: The ACA and Medicare
"Some states that have not adopted the [ACA] Medicaid expansions have stated concerns that the expansions may impair access to care and utilization for those who are already insured. [The authors] investigate such negative spillovers using a large panel of Medicare beneficiaries.... [R]esults suggest that the expansions in Medicaid did not impair access to care or utilization for the Medicare population." (National Bureau of Economic Research [NBER]; purchase required for full document)
[Official Guidance] CMS Announces 2019 Medicare Parts A & B Premiums and Deductibles
"The standard monthly premium for Medicare Part B enrollees will be $135.50 for 2019, an increase of $1.50 from $134 in 2018. An estimated 2 million Medicare beneficiaries (about 3.5%) will pay less than the full Part B standard monthly premium amount in 2019 due to the statutory hold harmless provision, which limits certain beneficiaries' increase in their Part B premium to be no greater than the increase in their Social Security benefits. The annual deductible for all Medicare Part B beneficiaries is $185 in 2019, an increase of $2 from the annual deductible $183 in 2018." (Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS])
Doctors Give Medicare's Proposal to Pay for Telemedicine Poor Prognosis
"The Trump administration wants Medicare for the first time to embrace telemedicine across the country by paying doctors $14 for a five-minute 'check-in' phone call with their patients. But many physicians say the proposed reimbursement will cover a service they already do for free. And the Medicare reimbursement -- intended to motivate doctors to communicate with patients outside the office -- could have a chilling effect on patients because they would be required to pay a 20 percent cost-sharing charge." (Kaiser Health News)
Six More Days: October 15 Deadline for Medicare Part D Notice of Creditable Coverage
"With the Medicare open enrollment period beginning next Monday (October [15] comes the annual reminder that the Part D Notice of Creditable Coverage is due to employees by the same date. The purpose of the Notice is to inform employees whether their employer-sponsored group health plan's prescription drug coverage is at least as rich as a Medicare Part D plan." (ABD Insurance & Financial Services)
Medicare Advantage Plans Shift Their Financial Risk To Doctors
"The 'global risk' model is increasingly used by Medicare plans such as Humana and UnitedHealthcare to shift their financial exposure from costly patients, giving doctors' groups more money upfront and control over patient care." (HealthLeaders Media)
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