HealthCare Roundtable e-News – December 19, 2022


Top News

The Roundtable and Other Stakeholders Send Letter to Departments on No Surprises Act

Last week, the Public Sector Health Care Roundtable and 58 other stakeholders sent a letter to the Secretaries of Health and Human Services (HHS), Labor, and the Treasury, urging the Departments to stand firm against efforts to strike down the No Surprises Act (NSA). Recent analysis estimates bipartisan enactment of the NSA prevented nine million surprise medical bills in the first nine months of 2022. However, the Texas Medical Association recently filed another federal lawsuit challenging the Departments’ NSA rulemaking, its third such lawsuit in the past year. The letters’ signatories asserted that previous litigation has diluted surprise billing regulations, leading to the excessive and costly use of Independent Dispute Resolution (IDR), and expressed concern that recent litigation may accelerate the overuse of IDR and increase health care inflation. They requested that the Departments reinforce guardrails around IDR via future rulemaking to ensure the NSA lowers healthcare costs as Congress intended.


CMS Proposes Requiring All Generics Be Placed on ACA Generic Drug Tier

Last Monday, the Centers for Medicare & Medicaid Services (CMS) released the 2023 Notice of Benefit and Payment Parameters Proposed Rule. The rule proposes requiring issuers of standardized plan options to place all covered generic drugs in a specific cost-sharing tier for generic drugs, or in a specialty drug tier if there is an appropriate, non-discriminatory basis for the decision. The rule would also require issuers of standardized plan options to place brand-name drugs that are not in a specialty drug tier in a preferred brand or non-preferred brand tier. The draft exchange rule contains a broad range of other policy proposals, including limiting the number of non-standardized plans insurers can offer and adding behavioral health care facilities to the list of essential community providers. The generic drug lobby has praised the Administration for the proposal.


CMS Proposes Changes to Expand IRA Low-Income Part D Access, Expand Use of Biosimilars

Last Wednesday, the Centers for Medicare & Medicaid Services (CMS) proposed tweaks to its implementation of the prescription drug provisions in the Inflation Reduction Act (IRA). The IRA states that individuals with incomes up to 150% of the Federal Poverty Level (FPL) and who meet statutory resource requirements will qualify for full low-income subsidies in Part D beginning Jan. 1, 2024. CMS proposes to expand eligibility for full low-income subsidies to also include individuals who currently qualify for partial low-income subsidies, a change the agency says would improve access to more affordable drug coverage and contribute to lower drug costs. The eligibility expansion would also ensure that those who qualify for full low-income subsidies face no deductibles, premiums, or fixed copay requirements for certain drugs. CMS also proposes making Medicare’s Limited Income Newly Eligible Transition (LI NET) Program a permanent fixture of the Part D program, as directed by the Consolidated Appropriations Act passed in 2021. In addition to changes aimed at ensuring equitable drug coverage access for low-income beneficiaries, CMS proposes that Part D plan sponsors be able to substitute brand drugs with lower-cost options in their formularies.

Administrative Action

  • CMS published the 2021 National Health Expenditures (NHE) Report which found U.S. health spending grew to $4.3 trillion in 2021, only a 2.7% increase over the prior year. Federal expenditures on COVID-19 supplemental funding and federal public health activities declined over 60%, driving much of the slowdown. Spending increased for each of the major funds sources: private health insurance (5.8%), Medicare (8.4%), Medicaid (9.2%) and out of pocket (10.4%) as well across the three largest service categories: hospital care (4.4%), physician and clinical services (5.6%), and retail prescription drugs (7.8%). The report also notes that enrollment in Medicaid and private insurance increased for the second consecutive year, decreasing the number of uninsured individuals.

  • HHS, through the Substance Abuse and Mental Health Services Administration (SAMHSA), proposed changes to federal regulations to expand access to treatment for opioid use disorder (OUD). The proposal would update 42 CFR Part 8 to improve access to and experiences with OUD treatment by allowing take home doses of methadone and the use of telehealth in initiating buprenorphine at opioid treatment programs (OTPS). According to Centers for Disease Control and Prevention (CDC) data, more than 107,000 Americans died from drug overdoses in 2021, an increase of more than 15 percent from 2020. This follows a 30 percent increase in overdose deaths from 2019 to 2020.

Congressional Action

Last week, the House Select Subcommittee on the Coronavirus Crisis published its final report assessing the nation’s response to the COVID-19 pandemic. The report claims that early warnings from the CDC were ignored or downplayed by leadership, and were followed by a federal response hampered by poor strategic planning. The subcommittee also highlighted how business relief funds, loans, and contracts were potentially improperly awarded or exploited by companies. Finally, the report concludes with 30 recommendations for federal activities and investments to prevent and respond to future public health emergencies, including: Adoption of the report will be the subcommittee’s final act during the December 14th hearing, unless the House Republicans decide to continue into the next session. 


  • CMS released their annual Medicare Advantage (MA) and Part D Proposed Rule for 2024 (fact sheet) which governs requirements for MA and Part D plans. Among its provisions, the rule includes stricter prior authorization requirements, increases beneficiary marketing protections, better incorporates health equity into Star Ratings, provider directories, and quality improvement programs, improves access to behavioral health, and expands access to the Medication Therapy Management (MTM) program. A summary of the proposed changes follows, and Healthsperien is in the process of developing a more detailed analysis of the rule.

  • CMS released the Center for Medicare and Medicaid Innovation’s (the Innovation Center) 2022 Report to Congress (RTC). The Innovation Center is required by statute to report to Congress on its activities, at minimum, every other year. This is the Innovation Center’s sixth RTC and covers activities from October 1, 2020 through September 30, 2022. During the period of report, the CMS Innovation Center had 33 models operational (either launched or continued).

  • The Committee for a Responsible Federal Budget, Employ America, and Paragon Health urged Congress in a letter to avoid any policy changes that would increase Medicare costs for fear of additional inflationary pressure. These policy changes include extending COVID-19 payment boosts or Medicare physician fee schedule increases, or suspending the Medicare sequester.


The Centers for Medicare and Medicaid Services (CMS) convened multiple federal health agencies at the We Can Do Better: Advancing Maternity Care Together meeting discussing the urgent need for a stronger, more diverse maternity care workforce and improved maternal health care navigation. At the convening, CMS introduced the logo for the Birthing-Friendly Hospital designation, which is a public designation of hospitals with quality and safe maternity care that CMS established earlier this year. The Department of Health and Human Services (HHS) also released a new report on doulas in maternal health care, which discusses how doulas can improve maternal and infant health outcomes, prevent birth complications, and help women navigate health care and social service systems.


HHS released their annual Notice of Benefit and Payment Parameters proposed rule for 2024 (fact sheet), which outlines requirements for issuers and Marketplaces. The rule notably includes several provisions to expand access to Marketplace coverage, including access to behavioral health care. As well, the proposed rule includes provisions related to network adequacy and access, plan options, reducing barriers to coverage, and user fees, risk adjustment, and program integrity.


  • Last month, the National Council on Disability (NCD) released a report outlining gaps in the current HCBS delivery system and providing recommendations to address these identified issues. Of note, the report identifies issues in lack of affordable and accessible housing and shortages in the current direct care workforce.

  • The Commonwealth Fund released a study showing that the U.S. has administered over 655 million COVID-19 doses and prevented over 18 million hospitalizations and 3 million deaths from COVID-19 in the process. The study showed that the rapid preparation and rollout of these vaccines have helped minimize the costly and potentially fatal consequences of COVID-19 and its variants. These findings highlight the importance of preventive care of vaccines in preventing infections, hospitalizations, and mortality while keeping children in school and businesses running.