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  1. #MedicarePlatform – Improve and Expand Medicare: Long-Term Services and Supports (LTSS)
  2. Center Submits Comments on Proposed Medicare Prescription Drug Rule
  3. Congressional Hearings Explore Rising Prescription Drug Costs
  4. Medicare’s New “What’s Covered” App Adds to Outreach but More Work Is Needed

#MedicarePlatform – Improve and Expand Medicare: Long-Term Services and Supports (LTSS)

Recently, the Center for Medicare Advocacy laid out our Medicare Platform for the New Congress. One of the core considerations to improve Medicare for all beneficiaries, now and in the future, is the need to preserve and expand consumer protections and quality coverage for all Medicare Beneficiaries – including parity between traditional Medicare and private Medicare plans. We previously wrote about limited access to Medigap plans, oral health care, and the lack of an out-of-pocket cap on beneficiary expenses in traditional Medicare.

One long-standing and significant gap in Medicare coverage is the lack of coverage for comprehensive long-term services and supports (LTSS, also known as long term care).  As discussed in a Center Special Report issued in September 2018, recent changes in law (namely the Bipartisan Budget Act of 2018, or BBA) and CMS policy have expanded the scope of both medical and non-medical services that Medicare Advantage (MA) plans can cover.  While MA coverage of LTSS appears limited so far, as noted in an AARP blog, this important extension of coverage leaves behind the majority of beneficiaries in traditional Medicare. 

This month, the Commonwealth Fund issued two companion reports exploring LTSS and Medicare beneficiaries: “Are Older Americans Getting the Long-Term Services and Supports They Need?” and “The Financial Hardship Faced by Older Americans Needing Long-Term Services and Supports”.

As summarized in the key findings of the report exploring financial hardship, 

Beneficiaries with high LTSS needs have higher Medicare and out-of-pocket spending than those without such needs and are more likely to report that medical care makes up part of their credit card debt. Those with high LTSS needs are also more likely to report trouble paying for food, rent, utilities, medical care, and prescription drugs. Many older Medicare beneficiaries using LTSS are vulnerable to incurring substantial costs. Without an affordable, sustainable financing solution, Medicare beneficiaries with LTSS needs will continue to be at greater risk of delaying necessary care, being placed in a nursing home prematurely, and having to “spend down” into the Medicaid program.

The report highlighting the need for such services finds that “[t]wo-thirds of older adults living in the community use some degree of LTSS.”  Noting that the “recent policy change allowing MA plans to offer LTSS benefits is an important step toward meeting the medical and nonmedical needs of Medicare beneficiaries, only the one-third of Medicare beneficiaries enrolled in MA plans stand to benefit.” Looking “[b]eyond the BBA” and policy that only expands LTSS in MA, the report notes that “other proposals could provide more flexibility (as well as broader accountability) in the traditional Medicare program to ensure the health and well-being of most Medicare beneficiaries.”

The Center agrees. It is imperative that beneficiaries in traditional Medicare have access to all the same coverage provided through Medicare Advantage plans. The Medicare program as a whole must be expanded to cover critical long term coverage/LTSS needs.

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Center Submits Comments on Proposed Medicare Prescription Drug Rule

The Center for Medicare Advocacy recently submitted comments to a Notice of Proposed Rulemaking issued by the Centers for Medicare & Medicaid Services (CMS) entitled “Modernizing Part D and Medicare Advantage to Lower Drug Prices and Reduce Out-of-Pocket Expenses” (CMS-4180-P).  The Center’s comments are available at: https://www.medicareadvocacy.org/center-comments-on-modernizing-part-d-and-medicare-advantage/.  

Currently, Part D prescription drug plans (PDPs) and Medicare Advantage prescription drug plans (MA-PDs) are required to include on their formularies all of the available drugs in six categories known as the “protected classes”: anti-depressants, antipsychotics, anticonvulsants, immunosuppressants for transplant rejection, antiretrovirals and antineoplastics. The proposed rule would allow plans to limit coverage of these drugs through new utilization management (UM) strategies, such as requiring certain patients to undergo step therapy (ST, aka “fail first”) or obtain prior authorization (PA). The proposal would also allow plans to completely exclude protected class drugs from their formularies and add additional hoops for beneficiaries to jump through absent adequate existing safeguards (e.g., effective exceptions, appeals, transition fills and formulary requirements).

The Center opposes these proposed changes because they would create barriers to life-saving medication. There is insufficient evidence of potential cost savings generated by the proposals, particularly in light of the serious access problems likely to be faced by beneficiaries.  Beneficiary protections are not currently robust enough to ensure beneficiary access, and would be even less sufficient under diminished protected class safeguards proposed under the rule; both our experience and external evidence demonstrate that current protections fall short.  As discussed in our comments, one area in which we do support the use of some utilization management within the protected classes concerns the inappropriate prescribing of anti-psychotics in the long-term care setting.

The Center also opposes CMS’ policy changes allowing Medicare Advantage (MA) plans to utilize step therapy on Part B drugs (first presented in 2018 sub-regulatory guidance, and now to be codified in this proposed rule). This policy will limit beneficiaries’ access to Part B drugs, including in the treatment of life-threatening conditions like cancer. 

We agree with CMS that the problem of high and rising drug prices must be addressed, however we disagree with the agency’s approach in this proposed rule, since it would likely impede access to vital medications.

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Congressional Hearings Explore Rising Prescription Drug Costs

On January 29, 2019, the Senate and House held separate hearings on prescription drug prices. The Senate Finance Committee’s hearing, Drug Pricing in America: A Prescription for Change, Part 1, explored the rising cost of prescription drugs and potential solutions to the ongoing crisis. In his opening testimony, Ranking Member Ron Wyden stated that “[m]ore than a decade of evidence shows that private Medicare Part D plans often do not do a good enough job of negotiating drug prices downward.” Senator Wyden added that “Medicare ought to be able to use the collective bargaining power of 43 million seniors to get better deals for patients and taxpayers.” In addition to allowing Medicare to negotiate drug prices, witnesses testified about additional policies that could lower overall drugs costs, including measures to improve the Medicare program. The hearing touched upon reducing the Part B add-on or moving to a flat fee payment, using reference pricing for setting reimbursement rates, drug rebates, and other initiatives.

Similarly, the House Committee on Oversight and Reform’s hearing, “Examining the Actions of Drug Companies in Raising Prescription Drug Prices,” examined actions driving increasing prices for prescription drugs and their impact on federal and state budgets. Chairman Elijah Cummings’ opening statement noted that “the ongoing escalation of prices by drug companies is simply unsustainable.” Witness testimonies included discussions about market exclusivity, patents, drug innovation and publicly-funded research, price transparency, as well as other measures discussed in the Senate hearing.

The Center for Medicare Advocacy previously submitted comments to the Senate Finance Committee on prescription drug pricing reform. For more information on some of the recommendations discussed in the Congressional hearings and in our comments, please see: https://www.medicareadvocacy.org/center-comments-on-prescription-drug-pricing-reform/.

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Medicare’s New “What’s Covered” App Adds to Outreach but More Work Is Needed

The Centers for Medicare & Medicaid Services (CMS) has released a free mobile app for iOS and Android users. The app, “What’s Covered,” is designed to provide Medicare beneficiaries and their families with a general overview of covered services, coverage requirements, costs, and additional information. While the app is geared towards beneficiaries in traditional Medicare, it notes that Medicare Advantage (MA) plans are required to cover the same benefits as those in traditional Medicare. Additionally, the app states that MA enrollees should contact their plans for information about covered and additional services.

Although the Center for Medicare Advocacy’s (the Center) review of the app is ongoing, it does add to outreach and education. However, CMS could improve the app by addressing the barriers to care that beneficiaries and families commonly experience. For instance, the Center still regularly hears from beneficiaries and families about the termination of skilled nursing and/or therapy services based on an erroneous “Improvement Standard.” Based on our initial review, however, the app does not address the Jimmo Settlement in any of the relevant sections (home health services, skilled nursing facility care, physical therapy, occupational therapy, and speech-language pathology services) to inform users that, contrary to ongoing misconceptions, Medicare does in fact cover skilled maintenance care or skilled care to maintain an individual’s condition, or prevent or slow decline. This is a missed opportunity to fully educate app users at critical moments, such as when a beneficiary receives his or her Notice of Medicare Non-Coverage.

Moreover, we also regularly hear from Medicare beneficiaries classified by hospitals as outpatients on observation status. Although these beneficiaries may be in a hospital for days or weeks, and receive the same care and services as inpatients, Medicare Part A will not cover their stay in the hospital or in a skilled nursing facility. As of March 2017, hospitals are required to give beneficiaries the Medicare Outpatient Observation Notice (MOON) within 36 hours if they are receiving “observation services as an outpatient” for 24 hours. Hospitals must also orally explain observation status and its financial consequences for patients, although beneficiaries have no right to an appeal. The apps’ relevant pages (outpatient hospital services and inpatient hospital care) do not discuss the possibility that a beneficiary could be in the hospital for days without being an inpatient or that a patient should expect to receive a MOON if he or she is classified as an outpatient on observation status. Again, this is a missed opportunity to fully inform beneficiaries and help them navigate another consequential problem in Medicare.

The Center will continue to monitor the “What’s Covered” app.  We hope to work with CMS to improve it.

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