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<< Older News  |  January 24, 2021

News

All News > Medicare

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Editor's Pick Comprehensive Explanation of the Medicare Part D Prescription Drug Benefit
Congressional Research Service [CRS] Link to more items from this source
Dec. 22, 2020

76 pages. "Medicare Part D has cost less than originally forecasted, due in part to lower-than-predicted enrollment and increased use of less expensive generic drugs. However, the Medicare Trustees project spending on Part D benefits will accelerate over the next 10 years due to the expectation of further increases in the number of enrollees, costs associated with the elimination of the out-of-pocket cost coverage gap in 2020, changes in the distribution of enrollees among coverage categories, a slowing of the trend toward greater generic drug utilization, and an increase in the usage and prices of specialty drugs." [R40611, updated Dec. 18, 2020]

Tags: Medicare  •  Prescription Drug Costs

The Effects of Medicare Buy-In Policies for Older Adults on Health Insurance Coverage and Health Care Spending
Urban Institute Link to more items from this source
Dec. 14, 2020

"[The authors] estimate the coverage and health care spending implications of a Medicare buy-in policy targeting adults ages 50 to 64, similar to proposed legislation.... The main finding ... is that a Medicare buy-in policy's potential to substantially expand health insurance coverage is limited given the subsidies already provided under the ACA. Buy-in enrollment does not exceed 3 million in any of our scenarios, including ones with lower premiums or much more generous subsidies than the ACA provides."

Tags: Health Plan Design  •  Medicare

HHS Eliminates Safe Harbor Protections for PBM Drug Rebates; Creates New Safe Harbors for Point-of-Service Discounts and PBM Fixed-Fee Arrangements
Sheppard Mullin Link to more items from this source
[Guidance Overview]
Dec. 3, 2020

"[T]he Final Rule amends the AKS discount safe harbor ... to eliminate safe harbor protection for drug discounts and rebates offered by pharmaceutical manufacturers to pharmacy benefit managers (PBMs), Medicare Part D prescription drug plan sponsors, and Medicaid managed care organizations.... [T]he Final Rule creates two new pharmaceutical-related safe harbors: [1] a safe harbor (the 'Point-of-Sale Safe Harbor') applicable to certain prescription drug point-of-sale discounts as offered to Medicare and Medicaid beneficiaries to reduce their direct out-of-pocket prescription drug costs and [2] a safe harbor (the 'PBM Service Fees Safe Harbor') applicable to flat fee arrangements paid by drug companies directly to PBMs for PBM services."

Tags: Medicare  •  Prescription Drug Costs

CMS Looks to Permanently Expand Telehealth Services
FierceHealthcare Link to more items from this source
Dec. 3, 2020

"The Trump administration added more than 60 telehealth services that will be reimbursable during the public health emergency caused by the COVID-19 pandemic. Those changes to telehealth coverage will also be allowed permanently in rural areas."

Tags: Health Plan Design  •  Medicare  •  Teleheath

CMS and HHS OIG Issue a Series of Final Rules to Reduce Prescription Drug Prices and Transition to Value-Based Care
Epstein Becker Green Link to more items from this source
[Guidance Overview]
Nov. 25, 2020

"[On] November 20, 2020, [CMS] and the [HHS] Office of the Inspector General ('OIG') published advance copies of a collection of four rules focusing on two themes: [1] reducing prescription drug prices and [2] advancing the transition to value-based care and modernizing the regulatory framework. This Client Alert provides a brief, high-level summary of each of the four rules[.]"

Tags: Medicare  •  Prescription Drug Costs

Litigation Filed to Challenge Administration’s Final Rule Permitting State-Sponsored Drug Importation from Canada
Council for Affordable Health Coverage [CAHC] Link to more items from this source
[Opinion]
Nov. 24, 2020

"FDA has noted it is struggling to keep up with approving medicines while working around the clock to support COVID-19 therapeutics and vaccine development. Despite this, the administration is willing to divert precious FDA resources away from these efforts and to expose Americans to the risks that come with drug importation schemes."

Tags: Medicare  •  Prescription Drug Costs

CMS Releases Interim Final Rule Establishing Reimbursement for Part B Drugs Based on International Pricing
Arent Fox Link to more items from this source
[Guidance Overview]
Nov. 24, 2020

"Who is and who is not subject to the model? ... What drugs are and are not subject to the model? ... How is the MFN price determined using international benchmarks? ... How is the payment amount determined? ... What other adjustments can be made to the payment amount? ... Non-payment provisions of note."

Tags: Medicare  •  Prescription Drug Costs

Is International Drug Pricing Suddenly at Our Doorstep?
Ropes & Gray LLP Link to more items from this source
[Guidance Overview]
Nov. 24, 2020

"[1] Which patients and providers are included? [2] Which drugs are included? [3] How will included drugs be paid for? [4] How will patients be impacted? [5] Is the IFR the same as the model previously proposed? [6] What are the MFN Model's federal price-reporting implications? [7] What does CMS estimate the costs to be?"

Tags: Medicare  •  Prescription Drug Costs

Trump Unveils Disputed, Long-Shot Drug Rules Upending Payment System
Bloomberg Law Link to more items from this source
[Opinion]
Nov. 24, 2020

"One policy changes drugmakers’ rebates to pharmacy middlemen such that they can’t fluctuate based on the price of the drug. With fixed payment arrangements, these pharmacy liaisons can expect less money. The rule also allows for discounts to go directly to customers at the pharmacy counter. Middlemen, also known as pharmacy benefit managers, help insurers organize their drug coverage lists and determine which products get preferential treatment. The other rule ties federal reimbursement for drugs administered in doctors’ offices to lower prices paid in other countries."

Tags: Medicare  •  Prescription Drug Costs

Administration Finalizes Most-Favored Nation Drug Pricing Rule
Rachel Sachs, in Health Affairs Blog Link to more items from this source
[Guidance Overview]
Nov. 23, 2020

"Rather than depending for its success on whether private sector firms volunteer for a novel, difficult task, CMS implements the IFR through the existing buy-and-bill model. Under the IFR, providers themselves will be reimbursed for the 50 Part B drugs that are the subject of the IFR program based on the most-favored-nations price.... CMS has now expanded the scope of the program, choosing to implement a mandatory nationwide program affecting most (though not all) Medicare providers."

Tags: Medicare  •  Prescription Drug Costs

Administration Implements Medicare Part B 'Most Favored Nation' Drug Pricing Reform
King & Spalding Link to more items from this source
[Guidance Overview]
Nov. 23, 2020

"The IFR, if it withstands judicial challenge, will restructure prescription drug payments to physicians, hospitals, and other providers and suppliers for the highest expenditure drugs eligible for reimbursement in the Medicare Part B program (commonly known as 'buy and bill' drugs). The [most favored nation (MFN)] Model's actual impact on drug prices, however, remains unclear. Below we describe the key elements of the MFN Model and offer a brief analysis of its potential impact and possible vulnerabilities."

Tags: Medicare  •  Prescription Drug Costs

Administration Finalizes Drug Pricing Rebate Rule
Rachel Sachs, in Health Affairs Blog Link to more items from this source
[Guidance Overview]
Nov. 23, 2020

"There appear to be no major structural changes between the NPRM and Friday's final rule (which is now scheduled to take effect in 2022, rather than in 2020, as originally proposed). But there are at least two points worth noting about the new release.... Removing Medicaid Managed Care Organizations ... Changing course by confirming that premiums and spending will not rise ... Like the most-favored-nation rule, the release of the final rebate rule came with additional legal complications that may jeopardize its implementation."

Tags: Medicare  •  Prescription Drug Costs

Text of HHS Final 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 Pharmacy Benefit Manager Service Fees
Office of Inspector General [OIG], U.S. Department of Health and Human Services [HHS] Link to more items from this source
[Official Guidance]
Nov. 23, 2020

345 pages. "Amending this regulation changes the definition of certain conduct that is protected from liability under the Federal anti-kickback statute, section 1128B(b) of the Social Security Act ... New regulatory text in the amendment revises the discount safe harbor. By excluding 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 or pharmacy benefit managers (PBMs) under contract with them, the Department modifies the existing discount safe harbor in particular contexts. Existing safe harbors otherwise remain unchanged. Safe harbors are also created for two additional types of arrangements. The first protects certain point-of-sale reductions in price on prescription pharmaceutical products, and the second protects certain PBM service fees."

Tags: Medicare  •  Prescription Drug Costs

Text of CMS Interim Final Rule with Comment Period: Most Favored Nation Model for Medicare Payments
Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS] Link to more items from this source
[Official Guidance]
Nov. 23, 2020

229 pages. "The MFN Model will test whether more closely aligning payment for Medicare Part B drugs and biologicals ... with international prices and removing incentives to use higher-cost drugs can control unsustainable growth in Medicare Part B spending without adversely affecting quality of care for beneficiaries.... These regulations are effective on [the date of publication in the Federal Register, currently scheduled for Nov. 27, 2020].... [C]omments must be received ... no later than [60 days after publication in the Federal Register]." [Also see: Fact Sheet on Most Favored Nation Model; ASPE report on rises in Medicare Part B drug spending; ASPE report on Medicare Part B drug spending and international price comparisons; and press release announcing this rule.]

Tags: Medicare  •  Prescription Drug Costs

President Trump Unveils Sweeping Reforms to Lower Drug Prices
HealthLeaders Media Link to more items from this source
Nov. 23, 2020

"[The cost of] Medicare Part B drugs ... [has] increased by 11.5% over the past five years. Medicare Part B drug spending of $30 billion in 2019 made up 14% of total Medicare FFS Part B spending, up from 11% in 2015. [CMS] is eliminating the Unapproved Drugs Initiative to stop price gouging by drug makers."

Tags: Medicare  •  Prescription Drug Costs

77% of Americans Unfamiliar with Proposals to Lower Medicare Age
InsuranceNewsNet.com Link to more items from this source
Nov. 17, 2020

"For those ... ages 55 to 64, most are worried about their ability to afford health insurance before reaching the current Medicare eligibility age of 65. Fifty-seven percent of the employed group is worried ... Thirty-three percent of those employed and unemployed and under 65 are planning to reduce preventive care appointments and/or everyday household purchases like groceries to afford health insurance before they reach 65.... Thirty-eight percent of the non-working group gets health insurance through either a former employer or a partner's employer[.]"

Tags: Health Plan Design  •  Medicare

Text of CMS Announcement: 2021 Medicare Parts A & B Premiums and Deductibles
Centers for Medicare & Medicaid Services [CMS], U.S. Department of Health and Human Services [HHS] Link to more items from this source
[Official Guidance]
Nov. 9, 2020

"The standard monthly premium for Medicare Part B enrollees [in 2021] will be $148.50 for 2021, an increase of $3.90 from $144.60 in 2020. The annual deductible for all Medicare Part B beneficiaries is $203 in 2021, an increase of $5 from the annual deductible of $198 in 2020.... The 2021 Part B total premiums for high-income beneficiaries are shown in [a] table ... The Medicare Part A inpatient hospital deductible that beneficiaries will pay when admitted to the hospital will be $1,484 in 2021, an increase of $76 from $1,408 in 2020."

Tags: Health Plan Costs  •  Medicare

COVID-19 Extension Guidance Makes the Interplay Between COBRA and Medicare (A Bit) Trickier
Verrill Dana LLP Link to more items from this source
[Guidance Overview]
Nov. 3, 2020

"Because the deadline for a qualified beneficiary to make a COBRA election typically occurs close in time to the date his or her coverage terminates, some employers have incorrectly assumed that COBRA continuation coverage must be offered only if the qualified beneficiary was entitled to Medicare before the qualified beneficiary's loss of coverage or qualifying event.... Because, under the Joint Notice, a qualified beneficiary's COBRA election could take place months after his or her qualifying event or loss of coverage date, employers must be sure to provide COBRA election notices to, and credit the COBRA elections of, qualified beneficiaries who enroll in Medicare after their qualifying event or loss of coverage date."

Tags: COBRA  •  Medicare

Sixth Circuit: Medicare Secondary Payer Act Prohibits Disparate Impact Discrimination
Arent Fox Link to more items from this source
Oct. 26, 2020

"This decision has the potential to upend any plan provision purporting to exclude dialysis treatments from network coverage and/or capping dialysis benefits at Medicare-based rates of payment.... [M]edical providers with valid assignments of all rights and benefits under ERISA may still be able to remedy plan terms that offend the MSP Act by asserting [1] an ERISA benefits claim and [2] an equitable claim for reformation of the plan to strike the unlawful terms.... The Ninth Circuit is set to opine on nearly identical issues in the coming months[.]" [DaVita, Inc. v. Marietta Mem. Hospital Employee Health Benefit Plan, No. 20-328 (6th Cir. Oct. 14, 2020)]

Tags: Health Plan Design  •  Medicare

Medicare Premiums for the First Two Years After Retirement Can Be a Nasty Surprise
Quarles & Brady LLP Link to more items from this source
Oct. 21, 2020

"Retirees, to some extent, can control post-retirement income and could have one eye on the IRMAA premium tables while they do so. Maybe at least so far as not going one dollar over an income bracket and suffering a premium increase for the whole bracket."

Tags: Medicare

How to Compliantly Transition Employees Into Retirement
Corporate Synergies Link to more items from this source
Oct. 21, 2020

"[T]he cost impact of an eligible employee's delayed retirement for one year can be equal to that of the combined sick leave and personal time off on a company-wide basis.... [One company] traced about 40% of their healthcare spend to a population of only 12% of their workforce, most of whom were eligible for Medicare or would be within two years. With an optional program in place to help older employees make end-of-career transitions, 60% chose retirement and/or moved to Medicare plans that fit their needs."

Tags: Medicare

CMS Head Says Value-Based Care Models Haven't Made Good Return on Investment
FierceHealthcare Link to more items from this source
Oct. 15, 2020

"[Seema Verma, the head of the Centers for Medicare & Medicaid Services (CMS)] did tout models that required providers to take on financial risk at a faster pace, potentially alluding to the direction CMS wants to steer value-based care models. 'I think the issue we have in value-based care is that many of our models unfortunately are not working the way we would like them to,' she said. 'They are not producing the types of savings the taxpayers deserve.' "

Tags: Health Plan Design  •  Medicare

Editor's Pick October 15 Deadline for Medicare Part D Notice of Creditable Coverage
ABD Insurance & Financial Services Link to more items from this source
[Guidance Overview]
Oct. 1, 2020

"Technically, employers must provide the Notice only to 'Part D eligible individuals' who are enrolled or seeking to enroll in the employer's prescription drug coverage. This includes all individuals enrolled in Medicare Part A or Part B who live in the service area of a Part D plan. As a practical matter, employers will not know which employees, spouses, or dependents are enrolled in Part A or Part B, and they will not know which individuals are seeking to enroll in the employer's plan. Therefore, employers generally provide the Notice to all employees."

Tags: Health Plan Administration  •  Medicare

Proposed Drug Discount Cards Will Be Funded by a Medicare Trust Fund
The Wall Street Journal; subscription may be required Link to more items from this source
Sept. 28, 2020

"A plan ... to send millions of prescription-drug discount cards to 33 million seniors will be funded by a Medicare trust fund ... Trust fund money is rarely spent on matters unrelated to the direct receipt of health care by seniors and people who are disabled. The plan to use the funds for a pilot program also comes as the pandemic has added pressure on the hospital-care trust."

Tags: Medicare  •  Prescription Drug Costs

HHS Takes Action as Part of President Trump's Healthcare Plan
U.S. Department of Health and Human Services [HHS] Link to more items from this source
[Guidance Overview]
Sept. 25, 2020

"President Trump unveiled his America First healthcare plan, signing an executive order to deliver Americans better care, lower costs, and more choice, continuing the work that HHS has been doing under his leadership.... HHS: [1] Issued a final rule and guidance from the Food and Drug Administration to open the first-ever pathway for states to use to safely import prescription drugs to lower patients drug costs. [2] Solicited private-sector proposals, as called for in the President's July executive order, on allowing Americans to get lower-cost FDA-approved drugs and insulins from American pharmacies via importation and reimportation. [3] Released the 2021 Medicare Advantage and Medicare Part D Premium landscape, showing that average 2021 premiums for Medicare Advantage plans are expected to decline 34.2 percent from 2017 while plan choice, benefits, and enrollment continue to increase, and that Part D premiums will be down 12 percent from 2017[.]"

Tags: Health Plan Costs  •  Health Plan Policy  •  Medicare  •  Prescription Drug Costs


<< Older News  |  January 24, 2021

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