The Centers for Medicare & Medicaid Services (CMS) released the second part of draft guidance for the Medicare Prescription Payment Plan that outlines requirements for Medicare Part D plan sponsors, including outreach and education requirements, pharmacy processes, and operational considerations, for the program’s first year, 2025. The draft guidance is part of the implementation of President Biden’s prescription drug law, the Inflation Reduction Act, which will help reduce the burden of high upfront out-of-pocket prescription drug costs for seniors and people with disabilities with Medicare prescription drug coverage by allowing them to spread out costs over the year rather than requiring they pay in one lump sum.

“Too many seniors and people with disabilities can’t afford to fill their prescriptions at the pharmacy – and that is unacceptable. Thanks to President Biden’s Inflation Reduction Act, certain Medicare patients will be able to spread their costs across smaller, monthly payments,” said Health and Human Services Secretary Xavier Becerra. “In addition to adding flexibility through a payment plan, the law cuts drug costs through provisions such as caps on out-of-pocket costs and the cost of insulin, and a mandate on drug companies to pay a rebate to Medicare if they raise prices faster than inflation. We are committed to ensuring that all people – including people with Medicare – receive the care they deserve at a cost they can afford.”

“One option under the Inflation Reduction Act is the Medicare Prescription Payment Plan, a program specially designed to help people with high drug costs have more predictable costs throughout the year,” said CMS Administrator Chiquita Brooks-LaSure. “People with Medicare prescription drug coverage should look at the Medicare Prescription Payment Plan as well as our Extra Help program to see what programs are right for them. CMS is continuing to implement the many important provisions of the Inflation Reduction Act on time to help older Americans and people with disabilities afford the care they need.”

Today’s draft guidance provides information on outreach, education, and communications requirements to ensure that people with Medicare Part D, particularly those who are most likely to benefit from this program, are aware of the Medicare Prescription Payment Plan. The guidance complements CMS’ forthcoming national education and outreach efforts to engage interested parties, including pharmacies, providers, and beneficiary advocates, on program implementation and ensure that they have the support and materials needed to communicate effectively on the program.

“Older Americans and people with disabilities who have experienced sticker shock from high prescription drug prices will have the option in 2025 to spread out-of-pocket costs out over the year, rather than paying all at once,” said Meena Seshamani, MD, PhD, CMS Deputy Administrator and Director of the Center for Medicare. “This specifically helps alleviate cash flow issues for people who face high out-of-pocket costs early in the year that may prevent these individuals from taking a drug that could keep them healthy. The draft guidance we have released is a blueprint to help operationalize this program to ensure both health care organizations and people with Medicare are empowered and educated. That way, people in Medicare can make the best choices for their health and financial needs.”

The Medicare Prescription Payment Plan, which goes into effect in 2025, is part of the Inflation Reduction Act’s suite of provisions aimed at lowering prescription drug and health care costs. Other provisions of the law are already helping to lower costs for people with Medicare. On January 1, 2024, the law expanded eligibility for the Low-Income Subsidy program (LIS or “Extra Help”) under Medicare Part D. Nearly 300,000 people with low and modest incomes currently enrolled are now benefitting from the program’s expansion, and 3 million people are eligible for the program but not yet enrolled. In addition, as of January 1, 2024, for some people enrolled in Medicare Part D who have very high drug costs, for the first time, their out-of-pocket costs will be capped at about $3,300 to $3,800 for most people. The Medicare Prescription Payment Plan complements these provisions by allowing individuals to spread their spending over the year rather than paying the total out-of-pocket cost upfront.

CMS is seeking comments from the public on today’s draft part two guidance. The comment period is open for 30 days. Comments received by March 16, 2024 will be considered during development of the final guidance. Comments should be sent to PartDPaymentPolicy@cms.hhs.gov with the following subject line: “Medicare Prescription Payment Plan Guidance – Part Two.”

The draft part two guidance builds on the previously released draft part one guidance and fact sheet (released on August 21, 2023). Final part one guidance is forthcoming.

For the draft part two guidance, please visit: https://www.cms.gov/files/document/medicare-prescription-payment-plan-draft-part-two-guidance.pdf

For the fact sheet on the draft part two guidance, please visit: https://www.cms.gov/files/document/fact-sheet-medicare-prescription-payment-plan-draft-two-guidance.pdf

For an implementation timeline for the Medicare Prescription Payment Plan, please visit: https://www.cms.gov/files/document/medicare-prescription-payment-plan-timeline.pdf

In response to the surging number of syphilis and congenital syphilis cases nationwide, the Department of Health and Human Services (HHS) is taking action to slow the spread with a focus on those most significantly impacted. Read the press release. As part of this effort, HHS is collaborating with CDC and the National Center for HIV, Viral Hepatitis, STD, and TB Prevention on a webinar for clinicians and other healthcare providers. Congenital syphilis occurs when pregnant people with syphilis pass the infection to their babies. Early screening, diagnosis, and treatment can prevent potential lifelong consequences. Speakers will explore missed opportunities for prevention. Registration page for the Wednesday, Feb. 28, 12:00 – 1:00 pm webinar.

The U.S. Department of Health and Human Services (HHS) Administration for Strategic Preparedness and Response updated the Risk Identification and Site Criticality (RISC) Toolkit. The RISC Toolkit is an objective, data-driven all-hazards risk assessment that can be used by public and private organizations within the healthcare and public health sectors to inform emergency preparedness planning, risk management activities, and resource investment. Use it for emergency preparedness planning and more.

SAMHSA’s updated toolkit provides guidance to a wide range of individuals on preventing and responding to an overdose. It also emphasizes that harm reduction and access to treatment are essential aspects of overdose prevention.

Last year, healthcare company bankruptcies increased to their highest level in five years, Modern Healthcare reports, citing Gibbins Advisors analysis. The advisory firm’s report, which looked at Chapter 11 bankruptcy case filings from 2019 to 2023, found 79 healthcare companies with more than $10 million in liabilities that filed for bankruptcy protection last year. Pharmaceutical and senior care companies made up nearly half of the list. The second-highest year for bankruptcies was 2019, with 51 companies filing.

Over the past several months, oversight of the COVID-19 Uninsured Program (UIP) by both the Health Resources and Services Administration (HRSA) and the HHS Office of Inspector General (OIG) has ramped up, according to Feldesman Leifer LLP (formerly Feldesman Tucker Leifer Fidell – FTLF). This increase in activity may be due to an OIG report issued in July of 2023 that stated, “[o]n the basis of our sample results, we estimated that nearly $784 million of $4.2 billion (or 19%) of UIP payments made to providers during our audit period for approximately 3.7 million of 19.2 million patients were improper.” In its response to the OIG audit report, HRSA states, among other things, that it will seek to recover improper payments to providers. In addition to the ongoing audits by the HHS OIG, the Division of Program Integrity of HRSA’s Provider Relief Bureau has recently begun random assessments of providers that received UIP funds using its team of contract audit firms. Central to the July OIG report are the terms and conditions that providers agreed to in order to bill the UIP fund for COVID testing and vaccine administration. In addition, the OIG has recently started audits of other providers including Health Centers focused on another, and rather unusual, provision of the terms and conditions. Health centers are urged to review the UIP terms and conditions, protocols for determining uninsured status as well as determine the amount of UIP payments received and how those funds were used and consider strategies to document, among other things, how your organization determined uninsured status and how it can document use of UIP funds. Read more.

With Medicare and Medicaid reimbursements on the horizon for services provided by Community Health Workers (CHWs), now may be a good time for organizations to consider hiring CHWs to assist patients/clients in accessing needed health and human services. Organizations hiring new-to-the-field CHWs can provide a full year of professional development to their CHWs by participating in Pennsylvania AHEC’s new state registered CHW Apprenticeship Program. Throughout the year, apprentices receive CHW training from Pennsylvania AHEC, structured on-the-job training, and intentional mentorship and supervision. At the end of the year, apprenticeship graduates will be qualified to be certified by the Pennsylvania Certification Board. Certification is expected to be a requirement for CHW services to be reimbursed. For more information, contact PA AHEC Program Manager Amanda Taylor Gehman.

1. How many people are currently on Medicaid in Pennsylvania? According to the most recent data from the PA Department of Human Services, as of December 2023, there are 3,287,641 million Medicaid recipients enrolled in the program.
2. How many have lost coverage since the end of the Medicaid Continuous Coverage requirement ended? Over 420,000
3. What is the transition plan once a beneficiary is no longer eligible for Medical Assistance? Will the transition be seamless to the beneficiary?

• When an individual’s Medical Assistance eligibility is terminated, they are sent a notice indicating why they were found to no longer be eligible and information on their appeal rights. If the closure is for a procedural reason, they may provide the missing information for up to 90 days after the case has closed and have their eligibility reconsidered and their case opened back to the date of closure if they are found to be eligible.
• If an adult is found to no longer be eligible for Medical Assistance due to financial reasons, they may be eligible for subsidized health care coverage on Pennie. Their case information is transferred automatically to Pennie and Pennie conducts outreach to the household with information about their coverage options and the level of subsidy they are eligible for.
• If a child is found to no longer be eligible for Medical Assistance due to financial reasons, they may be eligible for CHIP and will be transitioned into a CHIP category.

Pennie and the Pennsylvania Department of Revenue collaborated to connect uninsured tax filers to coverage through the Path to Pennie program. When uninsured tax filers complete their Pennsylvania state income tax return, they can fill out Tax Form REV-1882 – Health Insurance Coverage Information Request. The PA Department of Revenue will send the information provided on the form to Pennie to create an account. Pennie will then send a notice with three important pieces of information: an access code to open the newly created Pennie account; an estimate of financial assistance the consumer is likely to receive; and a 60-day Special Enrollment Period to apply, shop, and enroll in coverage.

Last summer, a group of six bipartisan Senators (called “the G6” for short) released a Request for Information (RFI) around several aspects of the 340B program. Last week, the G6 released a 50-page discussion draft of a bill for comprehensive 340B reform, entitled the SUSTAIN Act.

• Here is a link to a two-page overview of the 340B reform bill by the bipartisan group of six Senators, with a focus on issues of interest to FQHCs and Primary Care Associations (PCAs).
• A nine-page summary and explanation of the draft bill.
• A supplemental Request for Information by April 1 (incorporated into the summary document) around three of the most significant 340B issues: Contract Pharmacies; Patient Definition; and Hospital child sites.
• A letter to stakeholders that includes the following statement “We believe it is necessary to pass legislation in the 118th Congress that provides clarity, transparency, and accountability in the 340B program in order to ensure the program remains strong, long into the future.”