HealthCare Roundtable e-News – April 1, 2024



Top News

CMS Reports on Prescription Drug Savings due to Inflation Rebates from Provisions in the Inflation Reduction Act

The Centers for Medicare and Medicaid (CMS) reported that if drug companies increase prices faster than the inflation rate, 41 drugs available through Medicare Part B will have a lowered Part B coinsurance rate from April 1 to June 30, 2024. There are around 763,700 Medicare beneficiaries that utilize one or more of these 41 drugs each year. The Inflation Reduction Act aims to lower prescription drug costs and due to its Medicare Prescription Drug Inflation Rebate Program, Medicare beneficiaries using these drugs could save from $1 to $3,575 per average dose. The U.S. Department of Health and Human Services (HHS) Secretary Becerra applauded President Biden’s actions to lower drug prices and emphasized the importance of these cost savings for Americans, particularly older individuals and those with disabilities. When certain drug prices increase faster than the rate of inflation, the Inflation Reduction Act mandates that drug companies pay rebates to Medicare. By fall 2025, CMS expects to invoice prescription drug companies for the rebates owed to Medicare, and the rebate totals will be transferred to the Federal Supplementary Medical Insurance Trust Fund to support Medicare. In addition to the Medicare Prescription Drug Inflation Rebate Program, the Inflation Reduction Act has broadened eligibility under the Low-Income Subsidy program within Medicare Part D to lower health care costs. This expansion has allowed around 300,000 more people to benefit from the program and a current public education campaign aims to engage the other three million individuals who are eligible to enroll. The law also capped out-of-pocket costs at $3,500 at the beginning of this year for certain Medicare Part D beneficiaries and in 2025, all people with Medicare Part D will face a $2,000 cap on annual out-of-pocket prescription drug costs.


Commonwealth Fund Publishes Brief Examining How MA Plans Impact the Delivery of Care by PCPs

The Commonwealth Fund recently published an issue brief that examined whether primary care physicians (PCPs) who primarily serve Medicare Advantage (MA) patients report differences in care delivery, care coordination, and administrative burdens compared to those who mostly serve traditional Medicare patients. The analysis revealed that one in ten PCPs saw only MA patients, while about one in twenty saw only traditional Medicare patients. Additionally, findings from the brief show that there were few significant differences between how PCPs who mostly saw MA patients and those who mostly saw traditional Medicare patients engaged with and cared for people with chronic conditions. The brief also explained that PCPs who primarily saw MA patients were significantly more likely to receive notifications about their patients receiving care in other settings, indicating a better coordination of care compared to that of traditional Medicare. Notably, a majority PCPs reported that they are not regularly screening their Medicare patients for social needs, regardless of the plan type of the patient.

Administrative Action

  • The U.S. Department of Health and Human Services (HHS) recently released four new reports outlining the Biden-Harris Administration’s efforts to strengthen the Affordable Care Act (ACA). One of the reports, published by the Centers for Medicare and Medicaid Services (CMS), explains that over 21 million consumers either selected or were automatically re-enrolled in health insurance coverage through and State-based Marketplaces during the 2024 Open Enrollment Period. The other three reports published come from HHS’ Office of the Assistant Secretary for Planning and Evaluation (ASPE), which highlight current enrollment trends, enrollment trends broken down by race and ethnicity, and how the ACA Marketplaces have evolved and strengthened during the first ten years. These reports indicate that currently, over 45 million people have coverage due to the ACA’s Marketplaces and Medicaid expansion.


  • The U.S. Department of Health and Human Services (HHS), the Administration for Strategic Preparedness and Response (ASPR), and the Centers for Medicare and Medicaid (CMS) released a joint statement on the cyberattack against Change Healthcare that has impacted provider billing and claims operations. The letter highlights concerns from providers following the cyberattack about cash flow disruptions. The statement underscores that the Biden-Harris Administration is implementing flexibilities for state Medicaid programs to offer interim payments to fee-for-service providers and accelerating payments to providers and hospitals through Medicare. The Administration is encouraging health plans to take similar actions. HHS released resources for providers in response to the cyberattack including specific national contact information to receive information about availability of prospective payments or flexibilities. The resources contain information about how providers can connect with payers given the effects of the cyberattack. HHS included the email address if further contact information is necessary. The letter also promotes the HHS voluntary Healthcare and Public Health Cybersecurity Performance goals to strengthen healthcare organizations’ cyber preparedness.


  • The Biden-Harris Administration announced (fact sheet) actions to protect consumers from being enrolled in lower quality insurance plans. The actions taken come from the Departments of Health and Human Services, Labor and the Treasury (the Departments), which have released final rules regarding short-term, limited-duration insurance (STLDI) and independent, non-coordinated excepted benefits coverage, or “junk insurance.” STLDI is a type of health insurance that is typically utilized to fill temporary gaps in coverage when an individual is transitioning from one coverage plan to another. Notably, STLDI plans are not subject to the Affordable Care Act’s (ACA) critical consumer protections, which includes guaranteeing coverage for people with pre-existing conditions and prohibiting discrimination based on health status, age, or gender. The final rules released by the Departments will limit short-term plans from the current maximum of four years, to just four months. Additionally, part of the final rule will require health insurance companies to be transparent about what they offer to consumers. Short-term plans and fixed indemnity insurance policies that provide a fixed cash payment will have to include a digestible, concise consumer notice on marketing, application, enrollment and reenrollment materials to better inform consumers about their purchasing decisions. The maximum term and duration amendments to the definition of STLDI in the final rules apply for coverage periods beginning on or after September 1, 2024.


  • CMS released the FY25 hospice proposed rule (fact sheet, full rule). The proposed rule updates the FY25 hospice payment percentage by 2.6% and the aggregate cap amount for the coming fiscal year is set to grow to $34,364.85. The rule also proposes to adopt the most recent statistical area delineations, which would impact the hospice wage index, and proposes to clarify current policy related to the hospice “election statement” and the “notice of election” (NOE). The rule also proposed that two new Hospice Quality Reporting Program (HQRP) measures be collected via a new patient assessment tool, the Hospice Outcomes and Patient Evaluation (HOPE) tool. CMS proposed two HOPE-based measures and provides further information regarding future quality measure development. Lastly, the rule contains a request for information (RFI) soliciting comments from stakeholders regarding the implementation of a separate payment mechanism for high-intensity palliative care services. Comments on the proposed rule are due by May 28, 2024.


The Brookings Institute published a brief on outcomes under the No Surprises Act (NSA) arbitration process, known as the independent dispute resolution (IDR) process. The IDR process was implemented as a component of the NSA to adjudicate disputes between insurers and providers over payment for out-of-network services. The brief utilizes data released by the Centers for Medicare and Medicaid Services (CMS) on IDR disputes that occurred during the first half of 2023. The Brookings Institute focused on three types of professional services in its analysis: emergency care, imaging, and neonatal/ pediatric critical care. The analysis found that across the three types of services, the median IDR decision was at least 3.7 times what Medicare would pay. Moreover, the median price in comparison to historical mean in-network commercial prices, relative to Medicare, was at least 50% higher. The brief attributes these outcomes to providers submitting relatively high offers, and the IDR entities selection of the providers offer more three-quarters of the time. The report also concluded that there is a realistic possibility of the NSA raising in-network prices and premiums, contradictory to what the Congressional Budget Office predicted at enactment.

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