Centers for Medicare & Medicaid Services

On January 30, the Centers for Medicare & Medicaid Services’ (CMS’) Innovation Center announced that sickle cell disease (SCD) will be the first focus of the Cell and Gene Therapy (CGT) Access Model, a model for eligible states and pharmaceutical manufacturers designed to improve Medicaid beneficiaries’ access to cell and gene therapies.Continue Reading CMS Innovation Center Announces Sickle Cell Disease Focus under Cell and Gene Therapy Access Model

On November 2, 2023, the Centers for Medicare & Medicaid Services (“CMS”) released the calendar year (“CY”) 2024 Physician Fee Schedule (PFS) Final Rule (“CY 2024 PFS Final Rule”). The final rule reflects CMS’ broader strategy to promote a more equitable health care system.

Key Takeaways

  • In the CY 2024 PFS Final Rule,

On November 2, 2023, the Centers for Medicare & Medicaid Services (“CMS”) released the calendar year (“CY”) 2024 Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems Final Rule (“CY 2024 OPPS/ASC Final Rule”). The final rule with comment period finalizes payment rates and policy changes affecting Medicare services furnished in hospital

On October 17, 2023, CMS held their quarterly National Stakeholder Call to provide updates on recent accomplishments and how their initiatives advance CMS’ Strategic Plan. Administrator Chiquita Brooks-LaSure, kicked off the call by announcing the start of Medicare open-enrollment and how the entire agency is focused on educating beneficiaries on all 2024 benefits and encouraging people to renew their vaccinations which are available at no additional cost. Brooks-LaSure also revealed how for the first-time, high-cost prescription drugs will have a “catastrophic limit” in 2024. Dr. Meena Seshamani, the Director for the Center for Medicare explained that in 2024, Part D enrollees who reach what CMS calls “catastrophic fees” (the maximum threshold for paying out of pocket) will no longer have to pay a co-pay or out of pocket costs at the pharmacy. Dr. Seshamani also shared that beneficiaries taking insulin will not have to pay more than $35 for each supply of insulin products covered under part D and that people will not have to pay nothing out of pocket for recommended vaccines like shingles. CMS also spoke about the drugs selected for the Medicare Drug Price Negotiation program. CMS will have a patient-focused listening session on 11/15 for each selected drug to provide an opportunity for patients, beneficiaries, caregivers, and patient organizations can share relevant input for these selected drugs. Lastly, Dr. Seshamani shared that ACOs participating in the Medicare Shared Savings Program (MSSP) saved Medicare $1.8 billion in 2022. This is the 6th consecutive year that the program has generated overall savings, and the 2nd highest annual savings accrued for Medicare since the program’s inception.Continue Reading Current CMS Policy Priorities and Initiatives in Quarter 4

The Centers for Medicare & Medicaid Services (CMS) published new changes to the ACO REACH model to increase predictability for participating ACOs, protect against inappropriate risk score growth, and to advance health equity starting in performance year 2024 (PY2024). The ACO REACH model was created to deliver high-quality and coordinated care to patients while improving costs and health outcomes. Patients in a REACH ACO get help to manage chronic conditions, to receive more preventative health services, to receive care in more convenient ways like telehealth, and to better navigate the health system. When ACOs in the program achieve these goals of providing higher-quality care at a lower cost, they may be eligible to share in those savings. There are currently 132 ACOs participating in this model.Continue Reading CMS releases updates to the ACO REACH model to advance health equity and increase participation

Infographic outlining CMS' plan for Medicare beneficiaries to pay prescription drug costs in monthly installments. More information below.

On August 21, 2023, the Centers for Medicare & Medicaid Services (CMS) released draft guidance, pursuant to the Inflation Reduction Act (IRA), to implement the Medicare Prescription Payment Plan, a new program to help Medicare Part D beneficiaries more easily afford their out-of-pocket (OOP) costs for prescription drugs. The IRA, among other provisions aimed at lowering prescription drug costs for Medicare beneficiaries, requires, starting in 2025, that Medicare Part D plan sponsors offer beneficiaries the option to pay their OOP costs for prescription drugs monthly over a year instead of at the point of sale. Under the new program, referred to as the Medicare Prescription Payment Plan, Part D sponsors must pay the pharmacy the OOP cost-sharing that beneficiaries would have paid if they were not in the program. Part D plan sponsors then will bill beneficiaries monthly for their OOP responsibility.Continue Reading CMS Outlines Plan for Medicare Beneficiaries to Pay Prescription Drug Costs in Monthly Installments

The end of the COVID-19 public health emergency (PHE) has pushed government benefit programs to reassess the use of their data that will ultimately improve access to health care benefits and streamline their processes to provide health and social services. With the end of pandemic-era policies like continuous enrollment, beneficiaries have been losing coverage while states face challenges reviewing Medicaid eligibility and may benefit from data sharing across government programs. Prior to the end of the PHE, KFF estimated that between 8 million and 24 million beneficiaries would be disenrolled. As of August 23, close to 5.4 million Medicaid beneficiaries have been disenrolled; and 74% of disenrollees have had their coverage terminated due to procedural reasons (e.g. changed addresses, did not receive a form, or did not have enough information about the renewal process).[i] This means that individuals are disenrolled because they did not complete the renewal process within a specific time frame or the state has outdated contact information.Continue Reading Medicaid Redetermination Flexibilities and Data Sharing Under HIPAA

On June 21, the Centers for Medicare & Medicaid Services (“CMS”) issued a proposed notice with comment period outlining a transitional Medicare coverage pathway for emerging technologies through the national coverage determination (“NCD”) process in addition to several guidance documents that describe CMS’ approach to coverage reviews and evidence development, including the National Coverage Analysis Evidence Review and Clinical Endpoints Guidance: Knee Osteoarthritis.Continue Reading CMS Proposes Transitional Medicare Coverage Pathway for Emerging Technologies

The highly anticipated 2024 Medicare Physician Fee Schedule (PFS) was released earlier this month packed with changes that the Administration hopes will advance health equity and expand health service access to underserved populations. Some of the proposed rules emphasize certain Medicare programs like the Biden-Harris Administration’s Cancer Moonshot initiative and the largest accountable care organization (ACO) program, the Medicare Shared Savings Program (MSSP). Additionally, the new rule highlights primary care and contains provisions that align with HHS’ Initiative to Strengthen Primary Care.Continue Reading The 2024 Medicare Physician Fee Schedule Proposed Rule is Here: What you need to know

On July 10, 2023, the Center for Medicare & Medicaid Innovation (CMMI or “Innovation Center”) released a White Paper, Assessing Equity to Drive Health Care Improvements, outlining their analysis and assessment of health equity incorporation in model designs and evaluations. CMMI supports the development and testing of innovative health care payment and service delivery models. These innovation models are designed to improve quality of care and patient outcomes while reducing or maintaining program costs.[1]Continue Reading CMS Innovation Center Reports Data Challenges in Assessing Health Equity