New Medicare Advantage rules boost payments to plans, promise drug savings

DATE: April 4, 2018

Published by McKnight’s LTC News

Medicare Advantage plans will get 3.4% more in federal payments next year, while beneficiaries can hope for drug prices to decline.

The increase in the Centers for Medicare & Medicaid Services’ 2019 final rate notice and call letter released Monday is higher than the 1.84% raise proposed in February.

Last year, about one-third of Medicare beneficiaries enrolled in a managed care plan. Bloomberg Intelligence said there were 21.2 million members of such plans through March 2018, up from 19.8 million enrollees last April.

But too many of them, seniors and advocates say, still pay too much for their prescription drugs.

The 2019 revisions also finalized several new policies designed to reduce drug costs. Plans will be able to add generic drugs to their formularies at any time during the year, and increase the number of plan options available.

Still missing from the rule, which takes effect Jan. 1, is a decision on whether the discounts pharmacy benefit managers get for drugs should go toward lowering the actual price a patient pays.

Nor did the rule place strict limits on opioid dosing for long-term care providers.

“Based on preliminary review of more than 1,000 pages of new regulation and guidance, the Senior Care Pharmacy Coalition appreciates CMS’ sensitivity to the characteristics of the long-term care patient population in finalizing new Part D regulations and the 2019 Call Letter,” said Alan Rosenbloom, president and CEO of the Senior Care Pharmacy Coalition. “We are particularly gratified that the agency modified opioid control provisions based on the unique characteristics of long-term care patients and the heightened controls that long-term care pharmacies provide.”

Rosenbloom said he was still looking forward to finding out how CMS would handle “inappropriate” fees and payment adjustments that Part D Plans and their affiliated pharmacy benefits managers impose on LTC pharmacies.

“These practices increase drug costs for beneficiaries and the Medicare program, and we look forward to the Trump Administration’s anticipated plan to respond to high drug prices,” he added.

One group that wins in the new policies are home care providers.

The revisions expand Medicare Advantage benefits to non-medical services and supplies, including people and devices that might prevent or treat illness or injuries, compensate for physical impairments or address psychological needs.

Seth Sternberg, CEO and co-founder of non-medical provider Honor, called the decision “historic” in its recognition of the importance of at-home care.

“Home care workers are professional caregivers that can spot and prevent problems before they lead to complications or unnecessary hospitalizations, and should be a central part of Medicare Advantage providers’ care team,” he said.