HealthCare Roundtable e-News – October 26, 2021


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Preliminary Agenda


Stakeholders Await Details, Key Actions from House Reconciliation Bill Outline

Reports have begun to emerge on what lawmakers are planning to keep in President Biden’s highly anticipated reconciliation package as last minute efforts to negotiate policies have caused divides amongst Democrats. Key stakeholders, including those at family and patient advocate groups have been waiting patiently to see details on how the package’s policies will translate into actions.

Among key priorities still considered to be included in the package includes funding for increased Affordable Care Act subsidies, a Medicaid gap fix, and home-and-community based care are all policies, though according to Politico, a plan to replace Medicare dental benefits with a voucher program has been floated around while full coverage for vision and hearing are still included. 

Families USA associate director for strategic partnerships Melissa Burroughs has been a strong supporter of Medicare dental coverage and says that the group has heard “all kinds of things” about the status of Medicare dental coverage. According to Burroughs, there’s negotiating that needs to be done around potential voucher use dental coverage but believes that supporters are in a reasonable position and is hoping to see more details. (InsideHealthPolicy)

The price tag of the bill had recently been reduced from $3.5 trillion to $2 trillion after a number of setbacks from Republicans and, more notably, moderate Democrat Sens. Joe Manchin (W.Va.) and Sen. Kyrsten Sinema (Ariz.), who opposed key provisions like Medicare drug price negotiation and the president’s Clean Energy Performance Program, forcing leaders to lower expectations for those on the left.

House Speaker Nancy Pelosi (D-Calif.) shared that her party is planning to have an “agreement” on a framework for President Biden’s social safety net plan and a vote on the bipartisan infrastructure bill in the next week.

New CMS Guidance Focuses On Managing Medicare Advantage Marketing Actions

A recent guidance issued by CMS reveals how the Biden administration is planning to tighten its oversight into Medicare Advantage plans by offering tactics for monitoring marketing materials, lead generating activities, sales pitches and enrollment processes. According to stakeholders, the memo addresses how MA plans should manage their relationships with third party marketing agencies after the Trump administration had previously scaled back regulations around MA marketing.

The recent guidance asserts that MA organizations will be responsible for making sure that marketing materials used by third-party groups are submitted to CMS before they are used in order to ensure that the materials are not misleading to current or prospective enrollees. The guidance also offers best practices for MA marketing, including how plans should follow up with beneficiaries to make sure they understand the plan’s rules, how to look into disenrollment trends to see if third-party groups are acting in bad faith, and how to review calls between beneficiaries and agents to make sure the agents are in compliance, among other tactics. (InsideHealthPolicy)

“CMS is particularly concerned with national advertisements promoting MA plan benefits and cost savings, which are only available in limited-service areas or for limited groups of enrollees, as well as using words and imagery that may confuse beneficiaries or cause them to believe the advertisement is coming directly from the government. In addition, CMS receives complaints from beneficiaries and caregivers that highlight sales tactics designed to rush or push beneficiaries into enrolling into a plan,” the guidance says. (InsideHealthPolicy)

CBO Scores Key Health Care Provisions Debated in House Reconciliation Bill

Last week, the Congressional Budget Office and the Joint Committee of Taxation released their analysis of key provisions passed by House Committees leading up to the anticipated reconciliation package. The analysis includes scoring of a permanent extension of the American Rescue Plan’s increased Affordable Care Act tax credits and closure of the Medicaid gap, among other hot-button topics that have been debated by lawmakers in recent months. 

According to the CBO, about 4 million more Americans would have Medicaid over the 10-year period and 3.6 million would have subsidized coverage, while 1 million fewer people would be enrolled in unsubsidized individual market coverage and 2.8 fewer people would have employer-sponsored coverage under the bill. The CBO also found that permanently extending the tax credits would cost $209 billion, and the gap fix would cost $323 billion from 2022 to 20321. (InsideHealthPolicy)

Democrat lawmakers see the analysis as confirmation that the reconciliation package would be “transformative” for Americans. House Ways & Means Chair Richard Neal (D-Mass.) and Energy & Commerce Chair Frank Pallone (D-NJ) say the analysis confirms the actions both their committees took in drafting their respective components of the reconciliation package, “demonstrates the meaningful impact the Build Back Better Act will have on the lives of Americans and underscores the need to include these critical health care provisions in the final bill.” (InsideHealthPolicy)

Many Republicans say, however, the analysis affirms their suspicions that the policies are “untargeted” and may only benefit the wealthy. House Budget Committee ranking Republican Jason Smith (Mo.), who was the first to request the CBO estimates, and other House GOP leaders worry the health provisions “will further make individuals dependent on government-subsidized, government-controlled insurance coverage; ineffectively spend hundreds of billions of taxpayer dollars in exchange for only modest coverage gains; affect access to the job-based plans workers like and want to keep; and utilize budget gimmicks to manipulate and downplay the true cost of these policies.” (InsideHealthPolicy)

CMMI Chief Shares Plans to Address Social Determinants of Health in MA Models

The CMS innovation center shared last week that the Biden administration is continuing to review and evolve Medicare Advantage models that address the social determinants of health through supplemental benefits like non-medical transport, meal delivery and rental support.

CMMI chief strategy officer Purva Rawal confirmed the efforts at last week’s Better Medicare Alliance conference, telling attendees that some 3.7 million underserved MA enrollees will benefit from her agency’s models next year, pointing out that the program has seen significant growth in enrollment. However, many MA advocate groups say they would like to see long-term services and supports added as an MA plan supplemental benefit. Following Rawal’s remarks, a panel of experts suggested CMMI or lawmakers embrace long-term services and support benefits as the next area for growth in MA plans. (InsideHealthPolicy) 

Rawal also confirmed the administration wants to continue to evolve and iterate models that target reductions in cost-sharing or offer primarily or non-primarily health-related supplemental benefits to members that have particular health conditions or receive low-income subsidies. Rawal said that the ability to target, “and offer additional benefits for underserved communities that we think positions health plans … that participate in the VBID model to lead on health equity. And so this is going to continue to be kind of an important area of focus in our MA portfolio.” (InsideHealthPolicy)

Cyltezo Becomes First FDA-Approved Interchangeable Biosimilar on the Market

The FDA earlier this month approved the first interchangeable biosimilar version of Humira, what’s currently the top selling drug on the market. The drug, to be known in the market as Cyltezo, is slated to treat many similar conditions to Humira, from psoriasis to Crohn’s disease.

Cyltezo is manufactured by Boehringer Ingelheim and was first approved by the FDA back in 2017 but did not receive interchangeable status at the time. Now that it has, pharmacists may substitute the more expensive drug Humira for Cyltezo without needing approval from a patient’s healthcare provider.

Acting FDA Commissioner Janet Woodcock called the interchangeables approval path a way to help increase access to treatment options for patients with serious medical conditions. Woodcock called the approval as proof of the agency’s commitment “to provid[ing] patients with alternative high-quality, affordable medications that are proven to be safe and effective.”