HealthCare Roundtable e-News – March 4, 2024


Don’t Miss TODAY’S Webinar

CMS Action and the Public Sector: Navigating the Regulatory Landscape | Monday, March 4, 2024 | 3:30 to 5:00 PM (EST)

Join us for an insightful webinar focusing on CMS action and its implications for the public sector. We’ll delve into the challenges and opportunities arising from recent regulatory developments, including guidance on the Medicare Prescription Payment Plan and issues with copay smoothing, the CY 2025 Medicare Advantage Advanced Rate Notice, and general policies relating to the MA program. Don’t miss this chance to assess the landscape and gain valuable insights to navigate the evolving regulatory environment effectively.

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Top News

Roundtable Comments on CY 2025 Advanced Rate Notice

On March 1, the Public Sector HealthCare Roundtable submitted a comment letter on the Advance Notice of Methodological Changes for Calendar Year (CY) 2025 for Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies. The comment letter underscores the vulnerability of public sector entities to annual changes in federal MA payment policies, mainly because of their long-term contracts with insurers under Employer Group Waiver Plans (EGWPs), noting that these shifts could result in disproportionate effects during the risk adjustment phase. The Roundtable urged CMS to consider the complexities and nuances of EGWPs when making policy and regulatory changes to the MA program and offered its expertise as a resource to CMS. For the full letter, click here.


CMS Releases Final Part One Guidance for the Medicare Prescription Payment Plan

The Centers for Medicare & Medicaid Services (CMS) unveiled the final part one guidance for the Medicare Prescription Payment Plan, a component of President Biden’s Inflation Reduction Act of 2022 aimed at curbing prescription drug pricing. This guidance outlines operational requirements for Medicare Part D plan sponsors to facilitate the implementation of the program, which allows beneficiaries to spread out-of-pocket costs over the year instead of paying in full at the pharmacy counter. The final guidance mandates that Part D sponsors notify pharmacies to provide information on the program for individuals meeting a $600 out-of-pocket threshold, aimed at targeting communication to those who stand to benefit most. The Medicare Prescription Payment Plan aligns with other provisions of the Inflation Reduction Act, such as capping out-of-pocket costs for insulin and expanding eligibility for the Low-Income Subsidy program. CMS recently released the draft part two guidance for the program, which largely focuses on education and outreach in contrast with the part one guidance which focused on operational requirements. Public comments on the part two guidance will be accepted through March 16, 2024.

Notably, the Public Sector HealthCare Roundtable and its members submitted a comment letter on the draft part one guidance requesting an exemption for EGWPs from the spread out-of-pocket costs outlined in the program, which CMS denied.


Congressional Leaders Strike Fund Deal to Potentially Avoid Government Shutdown

Top lawmakers have reached a government funding deal on six annual spending bills in addition to a stopgap measure that would extend two shutdown deadlines later into March. Congressional leaders finished negotiating the Agriculture-FDA, Energy-Water, Military Construction-VA, Transportation-HUD, Interior-Environment and Commerce-Justice-Science bills, all of which will have a new deadline of March 8. Appropriators are aiming to release text by this weekend and pass the bills next week, funding these agencies through the end of the current fiscal year. The remaining fiscal year 2024 measures, including funding for the Pentagon, the Department of Homeland Security and the Departments of Labor, Health and Human Services and Education have a new deadline of March 22. Speaker Mike Johnson and other top lawmakers will continue to face challenges as they negotiate these bills before the deadline and Conservatives push for partisan policy riders. Both chambers now have just a few days to pass the stopgap continuing resolution before a partial government shutdown goes into effect on Friday at midnight. If Congress succeeds in meeting its funding deadlines this time, appropriators will need to immediately shift their focus to the next set of spending bills for the upcoming fiscal year starting on October 1st. President Biden is scheduled to unveil his fiscal 2025 budget request on March 11.

Administrative Action

  • The U.S. Department of Health and Human Services’ (HHS) Office of the Inspector General (OIG) released a report on the lessons learned during the pandemic and how they can be used to improve care in nursing homes. The report is based on two dozen interviews with nursing home administrators across the country delving into the barriers and challenges they faced during the pandemic. OIG found that at the pandemic’s peak in 2020, two in five Medicare beneficiaries in nursing homes were infected with COVID-19 and almost a thousand more beneficiaries died per day in April of 2020 compared to the same month in the year prior. The report also explains that over 1,300 nursing homes had extremely high infection rates of 75 percent or more, resulting in an average overall mortality rate approaching 20 percent during surges. Nursing homes cited monumental and ongoing staffing challenges, including a significant loss of staff and substantial difficulties in hiring, training, and retaining new staff. Based on their findings, OIG has recommended that the Centers for Medicare & Medicaid services (CMS) re-examine the current nursing staff requirements, update the nursing home requirements for infection control to incorporate lessons learned from the pandemic, and implement and expand upon its policies and programs to strengthen the nursing home workforce.


  • The Substance Abuse and Mental Health Services Administration (SAMHSA) has announced $36.9 million in funding opportunities to bolster behavioral health services nationwide, aligning with the priorities of the Biden-Harris Administration to combat the overdose and mental health crises. These grants aim to support community-based behavioral health services to foster positive outcomes and advance health equity. Some of the funding opportunities include $8.1 million for Prevention Technology Transfer Centers to enhance substance use prevention strategies, $10 million for Screening, Brief Intervention, and Referral to Treatment (SBIRT) programs targeting various age groups and settings, and $5 million for trauma-informed interventions for youth at clinical high risk for psychosis.


  • The U.S. Department of Health and Human Services (HHS), through the Administration for Community Living (ACL), revealed new programs and resources through ACL’s Direct Care Workforce (DCW) Strategies Center, a component of the HHS Health Workforce Initiative. The new initiatives include two technical assistance opportunities to help states improve their systems for hiring, retaining, and developing direct care workers. The first technical assistance opportunity is “DCW Intensive Technical Assistance” which will focus on collaboration among state agencies such as Medicaid, aging, disability, labor, and workforce development systems. The DCW Strategies Center will offer 250 hours of individualized technical assistance for up to six cross-agency state teams and focus on improving direct care workforce initiatives funded through the American Rescue Plan. The second technical assistance opportunity is “DCW Peer-Learning Collaboratives,” and this program will connect four to six states and form working groups to share innovative practices and models for increasing the direct care workforce. Additionally, ACL launched the DCW Strategies Center website, a national hub with resources for states, stakeholders, and communities, as well as a technical assistance webinar series—both initiatives will focus on strengthening the direct care workforce. These resources address concerns stemming from a shortage of workers who care for older adults and individuals with disabilities. These strategies will contribute to maintaining the effects of the $37 billion in American Rescue Plan funding that states have invested in home and community-based programs and support measures in the President’s executive order to enhance care.


Health Affairs published an article titled “A Surprise Benefit Of New Billing Dispute Rule: Reducing Administrative Burdens And Waste.” The article discusses the implementation of the No Surprises Act (NSA) in 2022, where patients have been removed from out-of-network billing disputes between health care providers and health insurers. While patients have benefitted from the NSA, providers and insurers have been plagued by delays and inefficiencies by a process called the independent dispute resolution (IDR). The IDR process was the foundation of the NSA, in eliminating patients from out-of-network disputes. The two main issues with the IDR process stem from overall volume of claims, and eligibility of the claim for arbitration. In hopes of rectifying these issues, the Departments of Health and Human Services (HHS), Labor (DOL), and Treasury (collectively the departments) recently proposed a rule aimed at addressing these fundamental issues with the IDR process. The departments proposed an open negotiation process, which would be guided by new communication and timeline requirements. Additionally, a unified online portal will be implemented to allow health insurers, providers, arbiters, and government officials to review each party’s work and increase transparency in the process. These changes hope to reduce the most common eligibility challenge, which is identifying whether the state or federal process applies to a dispute.

Mark your calendar:

Roundtable’s Congressional Forum

June 6, 2024

Washington, DC

Roundtable’s 20th Annual Conference

November 6-8, 2024

The Mayflower Hotel, Washington, DC

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