HealthCare Roundtable e-News – May 16, 2022

 

Top News

New York state will create an agency to supervise pharmacy benefit managers in an effort to keep drug costs low and protect consumers and small businesses. The new Pharmacy Benefits Bureau, under the Department of Financial Services, will be charged with licensing pharmacy benefit managers. The agency also will keep an eye on pharmacy benefit managers’ effect on consumers and the cost of health care. This announcement comes after Governor Kathy Hochul in January signed legislation requiring PBMs to get a license and conform to state standards in an effort to increase transparency on how drug prices are negotiated and whether savings are actually passed on to the insured.

Administrative Action

HHS announced the availability of $5 million for community health centers to increase equitable access to cancer screenings. This announcement supports President Biden’s Unity Agenda as part of the Administration’s Cancer Moonshot initiative. Funded by the Health Resources and Services Administration (HRSA), the funding aims to increase the number of health center patients screened for cervical, breast, and colorectal cancer. For information on the notice of funding opportunity, technical assistance, and other resources, please see here. Applications are due by Wednesday, June 15th.

HHS Secretary Becerra and CMS Administrator Brooks-LaSure sent a letter to state Governors on the Public Health Emergency (PHE). The letter reiterates the Administration’s commitment to providing Governors with 60 days’ notice but provides no further detail on whether the Administration anticipates renewing the PHE. If the Administration chooses to provide 60-days’ notice, we expect to learn whether the PHE will end by May 16th. The letter also strongly encourages states to use the full 12 months to conduct redeterminations for individuals enrolled in Medicaid and includes a summary of past guidance to states on the unwinding process and returning to regular operations post-PHE.

Regulatory Action

On April 29, 2022, CMS released the CY 2023 Medicare Advantage (MA) and Part D final rule (see press releasefact sheet), which revised MA and Part D regulations related to marketing and communications, quality ratings, network adequacy requirements, medical loss ratio reporting, requirements during public emergencies, and pharmacy price concessions. CMS also finalized significant regulatory changes to Dual-Eligible Special Needs Plans (D-SNPs), incorporating lessons learned from the Medicare-Medicaid Financial Alignment Initiative. Healthsperien has developed a detailed analysis of the final rule, which can be read here.

CMS finalized the Reassignment of Medicaid Provider Claims Rule, which will enable states to make payments to third parties on behalf of certain individual health care practitioners, including home care workers and personal care assistants. These changes would make it easier for those workers to obtain and retain health insurance, training, and other employee benefits. This rule came in response to a 2020 court ruling that vacated a 2019 final rule, which prohibited states from making these types of payments to third parties. The rule was finalized as proposed.

Congressional Action

U.S. Senators Bill Cassidy (R-LA) and Chris Murphy (D-CT), members of the Senate Health, Education, Labor, and Pensions (HELP) Committee, introduced the Mental Health Reform Reauthorization Act of 2022, which reauthorizes and builds upon key federal mental health and substance use disorder (SUD) programs that were part of the 2016 Mental Health Reform Act and are currently set to expire in September.

Senator Bernie Sanders (I-VT) and fourteen other senators introduced the Medicare for All Act of 2022. Implemented over a four-year period, the Medicare for All Act of 2022 establishes a federally administered national health insurance program that aims to ensure quality and comprehensive health care.

Rep. Susan DelBene’s legislation that would modernize prior authorization in Medicare Advantage, H.R. 3173 the Improving Senior’s Timely Access to Care Act, reached 290 co-sponsors. This means there are enough co-sponsors to warrant a vote on the House floor. If enacted the legislation would work to improve the prior authorization process.

  • Establishing an electronic prior authorization process;
  • Requiring HHS to establish a process for “real-time decisions” for items and services that are routinely approved;
  • Improving transparency by requiring MA plans to report to CMS on the extent of their use of prior authorization and the rate of approvals or denials; and
  • Encouraging plans to adopt prior authorization programs that adhere to evidence-based medical guidelines in consultation with physicians.

The legislation must maintain 290 or more cosponsors for 25 days. At which point it will be included on the House’s “Consensus Calendar” and will be brought to the floor for debate and a vote.

Marketplace

The Biden Administration released an inflation plan aimed at lowering costs and the federal deficit. Notably, the plan includes lowering prescription drug and health care costs. The plan proposes to fix the Affordable Care Act’s (ACA) “family glitch,” which has to do with who is eligible to receive premium tax credits when buying health insurance on the ACA marketplaces. The current IRS rule considers coverage affordable for a family if the coverage for the employee only does not cost more than this amount. It does not consider the affordability of family coverage. As a result, family members of workers — primarily low-income workers — are ineligible to receive premium tax credits through the marketplace even when family coverage is unaffordable.

Medicare

Health Affairs released a series of policy recommendations and research developments affecting the dual-eligible population. The series will run through August 2022, and Health Affairs is accepting submissions on a rolling basis. In this new article, Drs. Joynt, Maddox, and Johnston highlight existing disparities for dual eligibles’ access to care and health outcomes. To address these disparities, the authors argue for CMS to update current incentive structures within Medicare, which often disincentivize caring for this patient population. Program design, measure selection, and quality improvement are examples of such strategies to prioritize equity in CMS efforts.