5 Things About CMS' Finalized Policies for 2019


On Monday, CMS announced that it has finalized policies for Medicare health and drug plans for 2019 aimed to lower the cost of drugs for beneficiaries and provide additional plan choices.

On Monday, CMS announced that it has finalized policies for Medicare health and drug plans for 2019 aimed to lower the cost of drugs for beneficiaries and provide additional plan choices. Here are 5 takeaways from the policies:

1. Tackling prescription drug prices

As prescription drug prices remain a leading concern for Americans, the Trump Administration and FDA Commissioner Scott Gottlieb, MD, have voiced their commitments to lowering drug costs. Following suit, CMS has finalized policies to increase competition and lower the cost burden for beneficiaries, including a reduction in the maximum amount that low-income beneficiaries pay for biosimilars.

Other initiatives include allowing certain low-cost generic drugs to be substituted onto plan formularies any point during the year. To promote competition among plans, the agency is removing the requirement that certain Part D plans have to “meaningfully differ” from each other, which they say will make more plan options available. Among pharmacies, CMS says they will clarify the “any willing provider” requirement to increase the number of pharmacy options beneficiaries have to choose from.

2. Expanding the definition of “primarily health-related”

CMS is reinterpreting the standards for health-related supplemental benefits for Medicare Advantage plans to include additional services that increase health and improve quality of life. Under the new definition, the agency will allow supplemental benefits if they “compensate for physical impairments, diminish the impact of injuries or health conditions, and/or reduce avoidable emergency room utilization.”

While many Medicare Advantage plans already offer health benefits not traditionally covered by Medicare, such as eyeglasses, hearing aids, and dental care, the new policy will expand the list significantly to include services and items that may not be directly considered medical treatment.

3. Opening the door for vendors such as Amazon and Walmart to work with health insurers

CMS’ new rules for Medicare Advantage plans could have far-reaching effects, according to an article in Forbes. For health insurance companies like Aetna and Cigna, offering more supplemental benefits and an expanded definition of “primarily health-related” could result in them addressing of social determinants of health, which have increasingly become integrated in health programs, and generating initiatives to keep seniors out of the hospital setting.

This could also translate into new partnerships with companies, such as Amazon and Walmart, that have not historically been involved in health-related services.

4. Addressing the opioid epidemic

Amid nationwide efforts to combat the opioid epidemic, CMS said they are finalizing policies that respond to growing calls to address the epidemic. According to CMS, the policies provide Medicare with additional tools to combat opioid overprescribing and abuse, as well as protect families and communities nationwide.

Among these policies is a new authority that permits Part D sponsors to require beneficiaries at risk of addiction or overuse to use only selected prescribers or pharmacies for opioid prescriptions.

5. Patients Over Paperwork initiative

The final policies also include an advancement to the “Patients Over Paperwork” initiative. The initiative works to remove regulatory obstacles and empower patients to make informed healthcare decisions; develop innovative approaches to improving quality, accessibility, and affordability; and improve beneficiaries’ customer experience.

According to CMS, the final policies will allow the agency to use notice of electronic posting to fulfill disclosure requirements for certain bulky documents and streamline government review and approval of marketing materials Medicare health and drug plans use. Increasing the weight given to patient experience and access measures, the agency will improve transparency of the Star Ratings that provide beneficiaries information about each Medicare Advantage and Part D plan’s quality rating.

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