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Topic: Part D
On February 1, 2018, the Centers for Medicare & Medicaid Services (CMS) released its 2019 Advance Rate Notice (Part II) and Draft Call Letter. CMS estimates an expected increase of 1.84% to payments in 2019. CMS says its estimates do not reflect underlying coding trend, which it expects to increase risk scores by 3.1% in 2019.
“There’s no harm in hoping for the best as long as you’re prepared for the worst.”—Stephen King
As 2018 and Year 2 of the chaotic Trump Administration kick off, trying to predict what will happen in Medicare, Medicaid, and the Affordable Care Act is as challenging as ever. It’s a midterm election year with terrible headwinds for the GOP, so the legislative calendar is abbreviated, and partisan rancor will peak. That makes it less likely Republicans will get to do much damage but also more likely they will try to serve up red meat for their base, like a return to “repeal and replace.” Congressional leaders, fresh off their billionaire bailout tax bill, are already talking about taking up “reform” (aka cuts) of Medicare and Medicaid and other social welfare programs. The only thing that is certain is 2018 will be another battleground year for government health programs.
Among multiple policy changes to the 2018 Prescription Drug Benefit Program proposed, the Centers for Medicare & Medicaid Services (CMS) would revise existing policy related to tiering exceptions, including the permissible limitations Part D plan sponsors may apply to tiering exception requests. CMS is proposing to eliminate the provision allowing plans to exclude a dedicated generic tier from the tiering exceptions process and establish a framework based on the type of drug (brand, generic, biological product) requested and the cost-sharing of applicable alternative drugs. CMS is also proposing to clarify appropriate cost-sharing for approved requests when alternatives are on multiple lower tiers and to codify that authorized generic drugs should be treated as generics for purposes of tiering exceptions.
In 2016, 41 million individuals (72 percent of all Medicare beneficiaries) were enrolled in Medicare Part D. Of those enrolled, 60 percent were in stand-alone Prescription Drug Plans (PDPs), and 40 percent were in Medicare Advantage Prescription Drug plans (MA-PDs). Plan sponsors must adjudicate pharmacy claims for the Part D benefit in accordance with their Centers for Medicare & Medicaid Services (CMS)-approved formulary and Plan Benefit Package (PBP) bids.
Opioid overutilization and the corresponding public health crisis are ubiquitous in the daily news. In September 2017, the White House declared the opioid drug crisis was a national emergency. A presidential commission report described the opioid epidemic death rate as “September 11th every three weeks.” The map below, found on Consumer Protect, illustrates the number of opioid prescriptions by state in 2016.