Today, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that would make updates to the Medicare Advantage (MA) and Medicare Part D programs that would lower out-of-pocket prescription drug costs for beneficiaries with Medicare Part D and improve price transparency and market competition. The proposed rule would improve beneficiaries’ experiences with MA and Part D, with a strong emphasis on individuals who are dually eligible for Medicare and Medicaid. Ultimately, CMS is taking action to hold MA and Part D plans to a higher standard in offering benefits and improve health equity in the programs.

“We are dedicated to ensuring older Americans and those with disabilities who are served by the Medicare program have access to quality, affordable health care, including prescription drugs and therapies,” said CMS Administrator Chiquita Brooks-LaSure. “Today’s proposed actions follow our guiding principles by improving health equity and enhancing access to prescription medications.”

In recent years, more Part D plans and pharmacies have entered into arrangements—called price concessions—where plans pay less money to pharmacies for dispensed drugs if the pharmacies do not meet certain metrics. However, there is no public visibility on these pharmacy price concessions, and these lower prices are not passed along to the beneficiary at the point of sale. In late 2018, CMS sought comment on a policy that would require Part D plans to apply all price concessions they receive from network pharmacies at the point of sale, which would reduce beneficiary cost-sharing. Having considered the comments, CMS is now proposing this policy, which would take effect January 1, 2023, to reduce beneficiaries’ Medicare Part D out-of-pocket costs and improve price transparency and market competition in the Part D program.

The proposed rule also takes steps to improve experiences for dually eligible beneficiaries who are enrolled in Dual Eligible Special Needs Plans (D-SNPs). D-SNPs are plans offered by MA organizations that enroll individuals who are eligible for both Medicare and Medicaid. The proposed rule would require that MA organizations with a D-SNP establish, maintain, and consult with one or more enrollee advisory committees to ensure the experiences of people with both Medicare and Medicaid are considered in plan decision making. The proposed rule would also simplify materials that describe how to access Medicare and Medicaid services and streamline the grievance and appeals processes in certain D-SNPs. The rule also proposes a change to MA cost-sharing rules that would result in more equitable payments to providers who serve dually eligible individuals and may improve dually eligible individuals’ access to providers.

In addition, CMS is proposing actions that reduce health disparities by ensuring that all MA special needs plans solicit information about an individual’s barriers to accessing care, through standardized questions in required health risk assessments on housing instability, food insecurity, and transportation. Also, the proposed rule seeks to protect people with Medicare by ensuring they receive accurate and accessible information about Medicare coverage. For example, CMS is proposing to strengthen oversight of third-party marketing organizations that act, directly or indirectly, on behalf of MA organizations and Part D sponsors. These changes include requiring that MA and Part D plans provide information in all required beneficiary communications about the availability of free translation services.

This proposed rule also protects beneficiaries by holding plans to a higher standard when reviewing applications for new or expanded MA plans by requiring that plan applicants demonstrate a sufficient network of contracted providers to care for beneficiaries. CMS also proposes to limit MA plans’ ability to expand or enter into new contracts if their previous performance is poor. This rule further protects beneficiaries by clarifying requirements for plans during disasters and emergencies to ensure that beneficiaries have uninterrupted access to needed services.

CMS is also proposing to hold plans more accountable for how Medicare revenue is spent, including providing greater transparency regarding the amounts used to provide supplemental benefits (e.g., dental, vision, hearing, transportation, meals) by requiring MA and Part D plans to expand reporting of information on the percent of plan revenue spent on patient care and quality improvement activities, known as the medical loss ratio.

In order to increase our understanding of issues related to access to behavioral health care for enrollees in MA plans, the agency also seeks feedback on the challenges with building behavioral health provider networks within MA health plans and the overall impact of potential CMS policy changes on network adequacy and behavioral health access in MA plans.

For a fact sheet detailing the CY 2023 Medicare Advantage and Part D Proposed Rule (CMS-4192-P), please visit: https://www.cms.gov/newsroom/fact-sheets/cy-2023-medicare-advantage-and-part-d-proposed-rule-cms-4192-p.

To view the proposed rule, please visit: https://www.federalregister.gov/public-inspection.

The Centers for Medicare & Medicaid Services (CMS) issued guidance to state Medicaid officials on the scope of and payments for qualifying community-based mobile crisis intervention services authorized by the American Rescue Plan Act of 2021.  The guidance describes the requirements for qualifying services and provider qualifications, options for provider payments, and the requirements for receiving an increased federal share of costs.  States are encouraged to take into account additional travel time when developing services for rural areas.  Research has found higher proportions of rural populations have mental illness and substance use disorder compared to urban as well as challenges accessing care.

I am Carole Johnson, and this week, I am joining HRSA as the Administrator.  I am especially delighted to join HRSA in this role, having spent time earlier in my career as part of the agency’s health care workforce team.  Returning to HRSA as Administrator is an honor, and I look forward to working each day with the incredibly committed staff, grantees and partners who make up the HRSA community.  I want to share my appreciation for Deputy Administrator Diana Espinosa’s dedication to the communities that HRSA serves and leadership as Acting Administrator over the past year.

Like you, I am deeply committed to HRSA’s mission of improving health outcomes and achieving health equity.  I have seen firsthand HRSA’s tireless efforts to provide equitable access to COVID-19 vaccination and services and to support health care providers struggling with the financial impacts of the pandemic through my work with the White House COVID-19 Response Team.  As Commissioner of the New Jersey Department of Human Services, which provides health care and social services to one-in-five New Jerseyans, I saw the impact of HRSA programs on ensuring access to affordable primary care, supporting health professionals who serve in underserved communities, and reducing disparities in infant and maternal health outcomes and HIV care.  I have also had the opportunity to work closely with HRSA and others inside and outside of government on implementing the Affordable Care Act and combating the opioid epidemic.

It’s an extraordinary list of services and supports that this team delivers in communities across the country, and it only happens with the help and partnership of so many community leaders.  I look forward to hearing your thoughts and feedback on how we can become an even stronger agency as we work to advance health equity and improve access to care and services for those who need it most.

With best wishes for the new year,

Carole Johnson

The Appalachian Regional Commission (ARC) is pleased to announce that Maryland Governor Larry Hogan has been selected to serve as their states’ co-chair for 2022.

Governor Hogan will be working collaboratively with all 13 Appalachian states and the ARC federal office to advance the strategic investment priorities in ARC’s 2022-2026 Strategic Plan.

During FY 2021, ARC invested more than $163 million in the Region, which is projected to leverage an additional $1.04 billion in private investments, create or retain nearly 21,000 jobs, and train over 25,000 students, workers, and leaders in new skills across Appalachia.

During January, the Centers for Medicare & Medicaid Services Office of Minority Health (CMS OMH) recognizes National Poverty in America Awareness Month. There are 37.2 million Americans living in poverty, an increase of 3.3 million people since 2019. In 2020, racial and ethnic minorities continued to be disproportionately affected by poverty, with Black (19.5%) and Hispanic (17%) Americans shown to have poverty rates that were more than twice that of White Americans (8.2%).

There is a clear and established relationship between poverty, socioeconomic status, and health outcomes, with those living in poverty having an increased risk of chronic conditions, lower life expectancy, and barriers to receiving quality health care. The COVID-19 pandemic has also significantly impacted low-income families. In 2020, nearly half of lower-income families reported that they or someone in their household had lost a job or taken a pay cut as a result of the pandemic, impacting their abilities to meet basic economic needs and further disrupting access to health care. More specifically, these disparities in access to health care affected low-income families of color.

National Poverty in America Awareness Month offers an opportunity for CMS OMH to advance health equity for all Americans. CMS and other federal programs offer a variety of resources to help learn how to access health coverage, manage health care costs, and fully utilize benefits. Below is a list of resources that providers can share with their patients.

Resources

• Review the guide Using Z Codes: The Social Determinants of Health (SDOH) Data Journey to Better Outcomes, which provides step-by-step instructions for health care professionals on how to use Z codes which can enhance quality improvement activities, track factors that influence people’s health, and provide further insight into existing health inequities. Find out more data on Z codes in this data highlight.
• View the Coverage to Care (C2C) Roadmap to Better Care and a Healthier You to help others better understand their health coverage and how to use it to access primary care and preventive services.
• Review the Manage Your Health Care Costs to help patients better understand health insurance costs and terms, know specific health insurance costs, plan for health care costs, and know how to pay premiums.
• Read the C2C Prevention Resources to learn more about preventive services that are available to adults, teens, children, and infants, with many available at no cost under most health coverage.
• Review eligibility requirements for Medicaid in your state as well as the Children’s Health Insurance Program (CHIP), a federal and state program that provides health coverage to children in families with incomes too high to qualify for Medicaid but too low for private coverage.
• Visit the Programs of All-Inclusive Care for the Elderly (PACE) webpage to learn how this program helps to meet the health care needs of the elderly in their own communities.
• View the Medicare Savings Program webpage to learn how members in your community can get extra help from their state.

Help your community learn more about how the Administration for Children and Families Low-Income Home Energy Assistance Program(LIHEAP) and Temporary Assistance for Needy Families (TANF) is helping to assist households meet important expenses like heating and food.

On December 31, 2021, the Federal Communications Commission (FCC) launched the Affordable Connectivity Program (ACP). This longer-term program was created by Congress in the Infrastructure and Jobs Act, and replaces the Emergency Broadband Benefit program.  This investment in broadband affordability will help ensure households can afford the internet connections they need for work, school, health care and more.

To support your ACP outreach efforts, the FCC also launched a toolkit of materials for partners to download and customize to meet their needs. More materials will be added in the coming weeks, so continue to check the page for new additions.

The ACP provides a discount of up to $30 per month toward internet service for eligible households and up to $75 per month for households on qualifying Tribal lands. Eligible households can also receive a one-time discount of up to $100 to purchase a laptop, desktop computer, or tablet from participating providers if they contribute more than $10 and less than $50 toward the purchase price.

Enrollment in the ACP is now open for households with at least one member qualifying under any of the following criteria:

• Has an income that is at or below 200% of the federal poverty guidelines;
• Participates in certain assistance programs, such as SNAP, Medicaid, Federal Public Housing Assistance, SSI, WIC, or Lifeline;
• Participates in Tribal specific programs, such as Bureau of Indian Affairs General Assistance, Tribal TANF, or Food Distribution Program on Indian Reservations;
• Is approved to receive benefits under the free and reduced-price school lunch program or the school breakfast program, including through the USDA Community Eligibility Provision;
• Received a Federal Pell Grant during the current award year; or
• Meets the eligibility criteria for a participating provider’s existing low-income program.

As the FCC transitions to this new program, the over 9 million households fully enrolled in the Emergency Broadband Benefit Program as of December 31, 2021 will continue to receive their current monthly benefit until March 1, 2022.

More information about steps current Emergency Broadband Benefit recipients must take to continue receiving the Affordable Connectivity Program benefit after March 1, 2022 will be available in the coming weeks.

New tools are available to help consumers understand their rights

Beginning January 1, 2022, new federal protections championed by the Biden-Harris Administration will shield millions of consumers from surprise medical bills—unexpected bills from an out-of-network provider, out-of-network facility or out-of-network air ambulance provider. The protections, implemented under the No Surprises Act, ban surprise billing in private insurance for most emergency care and many instances of non-emergency care. They also require that uninsured and self-pay patients receive key information, including overviews of anticipated costs and details about their rights.

In addition to shielding millions of consumers from surprise medical bills, these protections will further President Joe Biden’s work to promote competition in health care and other sectors of the American economy.

“The No Surprises Act is the most critical consumer protection law since the Affordable Care Act,” said Health and Human Services (HHS) Secretary Xavier Becerra. “After years of bipartisan effort, we are finally providing hardworking Americans with the federal guardrails needed to shield them from surprise medical bills. We are taking patients out of the middle of the food fight between insurers and providers and ensuring they aren’t met with eye-popping, bankruptcy-inducing medical bills. This is the right thing to do, and it supports President Biden’s vision of creating a more transparent, competitive and fair health care system.”

“The No Surprises Act offers significant relief to people across the country, and reinforces our fundamental belief that no one should go bankrupt when seeking necessary care,” said Centers for Medicare & Medicaid Services (CMS) Administrator Chiquita Brooks-LaSure. “We are making it easy for consumers to know and understand their rights under the law, including what they can do if they receive a surprise medical bill. Consumers will not only benefit from these rights, but also will be empowered with the knowledge to address potential violations.”

A recent report from the HHS Office of the Assistant Secretary for Planning and Evaluation (ASPE) reviewed key evidence on surprise billing and the need for the consumer protections in the No Surprises Act. The report showed that surprise billing is common among those with private insurance—nearly one in five patients who go to the emergency room, have an elective surgery, or give birth in a hospital receive surprise bills, with average costs ranging from $750 to $2,600 per episode.

For Insured Individuals, Protections from Surprise Medical Bills

For people who have health coverage through an employer, a Health Insurance Marketplace®, or an individual health plan purchased directly from an insurer, the rules that took effect January 1, 2022:

• Bans surprise bills any time you receive emergency care, and require that cost sharing for these services, like co-pays, always be based on in-network rates, even when care is received without prior authorization.
• Bans surprise bills from certain out-of-network providers if you go to an in-network hospital for a procedure. This means cost sharing for certain additional services during your visit will generally be based on in-network rates.
• Requires providers and facilities to share with patients easy-to-understand notices that explain the applicable billing protections and who to contact if they have concerns that a provider or facility has violated the new surprise billing protections.

For Uninsured Individuals, Better Advanced Knowledge of Costs

For people who do not have health insurance or pay for care on their own (also known as “self-paying”), the rules that took effect January 1, 2022 require most providers to give a “good faith estimate” of costs before providing non-emergency care.

The good faith estimate must include expected charges for the primary item or service, as well as any other items or services that would reasonably be expected. For an uninsured or self-pay consumer getting surgery, for example, the estimate would include the cost of the surgery, as well as any labs, other tests, and anesthesia that might be used during the procedure.

Uninsured or self-pay consumers who receive a final bill that exceeds the good faith estimate by $400 or more can dispute the final charges.

Where to Learn More—Help Desk and Website

Both insured and uninsured/self-pay individuals who are concerned that their rights have been violated now have access to a host of tools, including a help desk (available at 800-985-3059, 8am-8pm ET seven days a week; TTY: 800-985-3059) and webpage (CMS.gov/nosurprises), where more details on registering potential violations can be found.

Although some states have enacted laws to reduce or eliminate surprise billing, comprehensive nationwide consumer protections were not available. But now, the No Surprises Act builds a national baseline of protections with a series of final and proposed rules issued in 2021, which complement existing laws in states where they already exist and protect all consumers nationwide. For more information on these rules, visit:

• Biden-Harris Administration Announces Steps to Protect Consumers and Improve Ground Ambulance Billing Practices Through No Surprises Act Implementation
• Biden-Harris Administration Improves Transparency and Oversight of Prescription Drug and Medical Costs
• Biden-Harris Administration Advances Key Protections Against Surprise Medical Bills, Giving Peace of Mind to Millions of Consumers Plagued by High Costs
• Biden-Harris Administration Issues Proposed Rules to Promote Transparency in Air Ambulance Costs, Agent and Broker Compensation
• HHS Announces Rule to Protect Consumers from Surprise Medical Bills