A final rule by the U.S. Department of Health and Human Services (HHS) and an interim final rule by the Centers for Medicare and Medicaid Services (CMS) that focus on drug costs in Medicare Part B and Part D were recently published.
While the rules were released as final and interim final, respectively, the road ahead is uncertain. It appears likely the rules will face legal challenges prior to or after the effective dates of their provisions. It is difficult to predict whether the policies finalized in these rules will reduce the total cost of drugs for the government and Medicare beneficiaries as intended.
Milliman professionals explore the two rules and explain their implications for Medicare drug pricing in this article.
In February, the Center for Medicare and Medicaid Innovation released a Request for Applications (RFA) for the Medicare Part D Payment Modernization Model (PMM). The PMM is a voluntary program whose goal is to reduce Part D federal reinsurance costs by adding new program flexibilities and introducing a two-sided risk-sharing arrangement around federal reinsurance costs. Interested Part D plan sponsors were required to submit an application to the Centers for Medicare and Medicaid Services (CMS) by March 15 in order to participate in the 2020 plan year.
There are many unknowns and questions regarding the PMM RFA. Some of these questions are:
• Who is eligible to participate (and who would want to)?
• What types of formulary or other program flexibility might be offered?
• What costs are associated with participating?
• Will this really result in Part D savings?
• How should plans determine information required for the application without insight on key program aspects?
• How would the benchmark be calculated?
• How could this be affected by the U.S. Department of Health and Human Services (HHS) proposal to move drug rebates to point of sale?
• What are the financial implications to the bid?
• What are the potential risks with participating?
In this article, Milliman’s actuaries discuss the answers to these questions.
Direct and indirect remuneration (DIR) has grown to be an important provision that Medicare Part D plan sponsors use to reduce their claim liabilities and thus member premiums. As DIR continues to increase, it is important for Part D sponsors to consider the effect of potential regulatory changes on plans’ bottom lines and operations. Milliman actuaries Deana Bell and Tracy Margiott provides some perspective in this article.
Financial dynamics and an evolving regulatory environment in the group retiree pharmacy benefits market continue to influence the relative values of Employer Group Waiver Plans (EGWPs) and Retiree Drug Subsidy (RDS) plans. Plan sponsors should periodically monitor and evaluate emerging trends in these programs to optimize plan value in this still-changing market.
Last summer, for example, the Centers for Medicare and Medicaid Services (CMS) announced a large decrease in the monthly direct subsidy revenue to EGWPs. Additionally, the Medicare Payment Advisory Commission (MedPAC) recently proposed changes to the Medicare program with major implications for EGWP costs.
Figure 1 summarizes key recent and proposed market and regulatory dynamics that are already impacting the relative values of EGWPs and RDS plans—and which could potentially influence further shifts in these values.
An evolving regulatory landscape is influencing the financial value of Employer Group Waiver Plans (EGWPs) and Retiree Drug Subsidy (RDS) plans. Plan sponsors should monitor the effect that new and proposed rules may have on their group retiree pharmacy benefits. In this article, Milliman actuaries Michelle Angeloni and Tracy Margiott discuss trends and changes affecting EGWPs and RDS plans as highlighted in Figure 2 below.