Estimated savings are $75 million over a decade.
Federal officials recently announced a series of changes to the Medicare Advantage (MA) and Part D prescription drug programs they hope will save tens of millions of dollars and also allow beneficiaries to make more informed purchasing choices.
The Centers for Medicare & Medicaid Services (CMS) announced the changes via a final rule that generally becomes effective for the 2022 plan year and could lower enrollee cost sharing on some of the most expensive prescription drugs available. Initial estimates projected $75.4 million in savings to the federal government over 10 years.
“The changes in this final rule provide desperately needed transparency on the out-of-pocket costs for prescription drugs that have been obscured for seniors,” Former CMS Administrator Seema Verma said in a statement. “It will strengthen Part D plans’ negotiating power with prescription drug manufacturers, so American patients can get a better deal.”
Tying in to the federal push for price transparency across the healthcare sector, the final rule will require Part D plans to offer a real-time benefit comparison tool, starting Jan. 1, 2023, so enrollees can obtain information about lower-cost alternative therapies under their prescription drug benefit plans.
Officials offered the following example: if a doctor recommends a specific cholesterol-lowering drug, the enrollee could look up what the co-pay would be and see if a different, similarly effective option might be cheaper – allowing them to know in advance what they will need to pay before heading to the pharmacy. It follows a similar CMS requirement that Part D plans support a prescriber real-time drug benefit tool that went into effect at the start of the current year.
“In the Medicare Part D program, enrollees choose the prescription drug plan that best meets their needs. Many plans offering prescription drug coverage place drugs into different ‘tiers’ on their formularies,” CMS noted in a press release. “Today, all drugs on a plan’s specialty tier – the tier that has the highest-cost drugs – have the same level of cost sharing. Under the final rule, CMS is allowing Part D plans to have a second, ‘preferred’ specialty tier with a lower cost sharing level than their other specialty tier. This change gives Part D plans more tools to negotiate better deals with manufacturers on the highest-cost drugs and lower out-of-pocket costs for enrollees in exchange for placing these products on the ‘preferred’ specialty tier.”
For a fact sheet on the final rule, go online to: https://www.cms.gov/newsroom/fact-sheets/contract-year-2022-medicare-advantage-and-part-d-final-rule-cms-4190-f2-fact-sheet
The final rule can also be downloaded in its entirety from the Federal Register at: https://www.federalregister.gov/public-inspection/2021-00538/medicare-and-medicaid-programs-contract-year-2022-policy-and-technical-changes-to-the-medicare
Hierarchical Condition Categories (HCCs) and value-based care have been a major focus for healthcare organizations during recent years. As many of you may know, the
This is the season for reporting proposed and final payment rules for FY 2024. After a brief pause during the winter months, the Centers for
Please log in to your account to comment on this article.
Dr. Ronald Hirsch provides tried-and-true strategies and insight into outpatient in hospital bed stays including determining the applicable definition, who uses it, and when and how to bill for this circumstance, solidified with concrete case examples and expert insight.
Practical solutions for CDM departments to protect your hospital’s revenue.
This webcast teaches hospitals how to comply with CMS price transparency rules and compare their rates with peer hospitals. It covers creating a compliant machine-readable file, comparing negotiated rates, and improving pricing decisions.
The No Surprises Act (NSA) presents a challenge for hospitals and providers who must provide Good Faith Estimates (GFEs) for all schedulable services for self-pay and uninsured patients. Compliance is necessary, but few hospitals have been able to fully comply with the requirements despite being a year into the NSA. This webcast provides an overview of the NSA/GFE policy, its impact, and a step-by-step process to adhere to the requirements and avoid non-compliance penalties.
This expert-guided webcast will showcase tips for providers to ensure appropriate capture of the work performed for a visit. Comprehensive examples will be given that demonstrate documentation gaps and how to educate providers on the documentation necessary to appropriately assign a level of service. You will gain clarification on answers regarding emergency department and urgent care coding circumstances as well as a review of how/when it is appropriate to code for E&M in radiology and more.
Set yourself up for financial and compliance success with expert guidance that breaks down the impactful changes including MS-DRG methodology, surgical hierarchy updates, and many new technology add-on payments (NTAPs). Identify areas of potential challenge ahead of time and master solutions for all 2024 Proposed IPPS changes.
Do you struggle with selecting and appending the correct modifier for your medical claims? Join our must-attend webinar, “Mastering Modifier Usage: Preventing Denials and Ensuring Compliance” to reduce claim denials and improve your reimbursement rates.
Kay Piper reviews the guidance and updates coders and CDISs on important information in the AHA’s fourth quarter 2023 ICD-10-CM/PCS Quarterly Coding Clinic in an easy to access on-demand webcast.
Copyright © 2023 ICD10monitor. Powered by MedLearn Media.
