Medicare Advantage and Part D Rule: A win for patients, but out-of-pocket costs must be capped

Click here to view original web page at

Medicare Advantage and Part D Rule: A win for patients, but out-of-pocket costs must be capped
© Getty Images

Taking steps to control costs while ensuring high-quality care, empowering patients with information, and improving transparency across our health care system are critical. That is why after months of advocating for patient protections and transparent pricing, the National Health Council (NHC) was pleased the Centers for Medicare and Medicaid Services (CMS) finalized its Medicare Advantage and Part D Prescription Drug Price Rule, which maintained proposed transparency provisions that the NHC supported, while removing or mitigating harmful proposed provisions.

We fully support efforts to increase price and cost-sharing transparency, and for the implementation of robust mechanisms to ensure any price concessions extended to Part D Plans are passed on to patients. However, there is also a need for an out-of-pocket cost cap – something Congress is currently debating.

Originally, we had significant concerns with the administration’s proposal to give Medicare plans more flexibility to impose new barriers, keeping patients from receiving needed medicines in a timely fashion. For example, changes to the Medicare Part D six protected classes would have allowed plans to stop covering some medicines for conditions such as cancer, mental health illnesses, and HIV/AIDS. We are pleased that CMS rolled back these changes. We thank the administration for listening to the concerns of beneficiaries and for not restricting access to needed medications.

We had been especially concerned about step-therapy requirements, which can be particularly onerous for patients with chronic conditions. For example, after living for years with psoriatic arthritis, a painful skin and joint condition, Katie Roberts found help through a biologic drug that got her out of a wheelchair and back to living a normal life. Out of the blue, her insurance company refused to pay for the medicine she relied on.

Instead, the insurer required her to go through step therapy, making her test and fail numerous other drugs before it would pay for the medication she and her doctors already knew worked. She was back in a wheelchair in 4 weeks and developed new chronic conditions that are still with her today. Her doctors were powerless to fight the insurer’s decision. Her medical history and her doctors’ medical opinions didn’t matter to the insurer. The process was not transparent, as there were no stipulations on how many medications she would have to try and fail to get to the one that worked. These challenges are far too common for people with employer-sponsored coverage like Katie, which is why we are concerned with the idea of expanding these practices into Medicare.

To help patients, the NHC requested additional patient protections in the CMS policy that would allow Medicare Advantage plans to impose step therapy for doctor-administered drugs. Consistent with our recommendations, the administration is now incorporating a longer “look-back” period of one year, allowing patients uninterrupted and non-duplicative care. This is important because many doctor-administered infusions are delivered less frequently than pills, so someone may be stable on a medication, even if they haven’t needed to take it in the previous four or five months. Additionally, CMS will require all plans to submit their step-therapy protocols for CMS review.

The final rule also maintained some proposed provisions the NHC strongly supported. For example, in 2021, CMS will require Part D plan sponsors to implement an electronic, real-time benefit tool to enable prescribers and patients to make better choices at the point of prescribing. Additionally, CMS finalized a new requirement that prescription drug plans must disclose pricing information for each medicine in the explanation of benefits. We agree with CMS when it states these improvements will “spark dialogue between the Part D beneficiaries and their providers about lower-cost therapeutic alternatives.” That’s a win for everyone.

Additionally, the rule bans “gag clauses.” Most people were unaware that some pharmacy-benefit-manager (PBM) contracts prohibit pharmacists from telling patients that their medications may cost less when the they pay with cash instead of using insurance. Under the rule change, these contracting clauses are no longer allowed. Your pharmacist can, without prompting, tell you about the lowest-cost payment options. Giving patients more choice, making drug pricing more transparent, and providing access to more affordable prescription medications is another big win in our book.

We are now looking to capitalize on these improvements to the Part D program by turning our attention to Congress as it debates legislation to put a limit on the out-of-pocket costs seniors pay for their prescription drugs. Since its launch in 2007, the Part D prescription drug program has been instrumental in expanding drug access for Medicare beneficiaries. However, it remains the only type of health insurance in our country that does not have a limit on out of pocket costs. This has become problematic in recent years, as according to the Medicare Payment Advisory Commission (MedPAC), spending for high-cost enrollees grew from about 40 percent of total program costs before 2011 to 58 percent in 2016.

Congress has expressed willingness to tackle the issue, as the bipartisan leaders of two House Committees released at the end of May a draft bill for stakeholder input. Additionally, President Trump signaled support for such a proposal in his budget earlier this year. While the details are evolving, a limit on out-of-pocket costs will be one of the most meaningful changes to the Medicare drug program since its inception.

The NHC, which represents more than 160 million people with chronic conditions and their family caregivers, calls on Congress and the administration to limit out-of-pocket costs in Part D – seniors deserve it.

Marc Boutin is chief executive officer of National Health Council.

Leave a Reply

Your email address will not be published. Required fields are marked *