Health Policy Report

CMS Finalizes 2020 Exchange Rule

Thursday, the Centers for Medicare and Medicaid Services (CMS) finalized its 2020 Notice of Benefit and Payment Parameters, the annual rule that establishes standards for health plan issuers and the exchanges. Although CMS had proposed three prescription drug-related provisions, it finalized just one of them to allow plans to exclude manufacturer-issued copay coupons from beneficiaries’ out-of-pocket (OOP) costs as they relate to the annual OOP cap. CMS also finalized a controversial change to its premium adjustment percentage index, which will increase net premiums, reduce exchange enrollment, and reduce premium tax credits available to subsidy-eligible beneficiaries. CMS declined to finalize provisions that would have ended automatic re-enrollment in health plans and subsidies. These changes will apply to plans for the 2020 plan year and beyond.

As CMS simply solicited comment on “silver loading” in the proposed rule, the agency chose not to finalize any policy on the topic. It noted that all commenters supported silver loading “as an option to maintain consumer affordability and participation.” However, CMS said that some commenters suggested a phased-in limitation on silver loading if cost-sharing reduction funding is provided by Congress. CMS gave no indication of what its future plans for silver loading might be.

Acting FDA Commissioner Sharpless to Continue Gottlieb’s Vision for Agency

In a speech at the Food and Drug Administration on Tuesday, Acting FDA Commissioner Ned Sharpless confirmed he will not stray far from FDA’s current goals laid out by former commissioner Scott Gottlieb’s leadership. He went on to explain that the agency will continue its work to increase competition and bring down pharmaceutical costs, regulate tobacco products including e-cigarettes, reform dietary supplement oversight, and push for the increased use of real-world evidence for novel medical devices. The Acting Commissioner, whose first day was April 8, emphasized he is especially eager to work on FDA’s food safety and nutrition efforts.

Many stakeholders had recently raised concerns that the departure of former Commissioner Gottlieb would halt the agency’s advancement over the past two years, but Acting Commissioner Sharpless assured those present that the change in leadership would not halt the FDA’s progress on their goals. The FDA was especially busy last month as former Commissioner Gottlieb prepared to leave while essentially laying out a “to-do list” for the Agency’s future leadership. Additionally, Acting Commissioner Sharpless stated Tuesday he wasn’t planning any radical departures from the work done under Gottlieb, and had already spoken to many Congressional leaders to reiterate this point.

Administration Sets up Medicaid Work Requirement Case for Potential Supreme Court Review

The Centers for Medicare & Medicaid Services (CMS) last week asked for an accelerated appeal in the litigation over Medicaid work requirements in Arkansas and Kentucky, arguing that the district judge’s recent decision to invalidate their use will cause “significant disruption to the detriment of the states and the federal government.” The Administration noted in court papers that an accelerated schedule would allow the case to potentially be reviewed by the Supreme Court during the 2019-2020 term. Requests for expedited appeals are granted very rarely and are typically reserved for cases in which a speedy resolution would serve the public interest or avoid a risk of permanent harm.

Medicaid beneficiary advocates have already opposed the request over arguments it fails to meet the usual criterial for expedited review and that the process is usually reserved for national security cases. They noted that accelerated appeal should not be used to “give the government an EZ Pass…or privilege the government’s cases above all others.” CMS maintains that the expedited appeal is necessary to avoid an extended period of uncertainty for beneficiaries in states with work requirements or those looking to implement them. The administration has asked that the D.C. Circuit hear oral arguments in the case within the first week after its summer recess.

CMS Proposes 2.3 Percent Payment Increase for Inpatient Rehabilitation Facilities

Wednesday, The Centers for Medicare & Medicaid Services (CMS) proposed a rule with several payment and policy changes designed to continue the Agency’s efforts towards eventual transition to a unified post-acute care (PAC) system. The Fiscal Year 2020 Payment and Policy Changes for Medicare Inpatient Rehabilitation Facilities proposed rule, would update the Prospective Payment System (PPS) rates for IRFs for discharges beginning October 1 and provide a larger bump in pay for facilities in rural areas than urban areas. The proposed rule is scheduled to be published in the April 29th edition of the Federal Register, with an anticipated comment deadline of June 17.

The proposed rule would provide a 2.3 percent overall increase in discharge payments for inpatient rehabilitation facilities, putting the total estimated pay increase at $195 million. The rule proposes a 4.3 percent increase for facilities in rural areas compared to fiscal year 2019 payments, and 2.2 percent for facilities in urban areas. Payments per discharge for freestanding rehabilitation hospitals would see no change in urban areas and face a 2 percent decrease in rural areas. The proposed rule suggests moving the wage index to the same one used for hospitals under the inpatient PPS to better align wage index methodology across all post-acute care settings. Additionally, it provides details about the data used for IRF payments, including revising case-mix groups (CMG) that are set to take effect in FY 2020 and updating the CMG relative weights and average length of stay. CMS specifically requested input on changes to the calculation of the wage index for IRFs and case-mix groups.

The proposed rule also continues the agency’s focus on advancing quality and safety. To this end, CMS proposed to adopt two additional measures related to the transfer of health information under the IRF Quality Reporting Program (QRP) in an effort to improve the interoperability of health records and ensure patient medication lists are accurate at the time of transfer or discharge. These proposed measures are intended to satisfy the IMPACT Act requirements. Other proposed changes to the QRP will require IRFs to report all patient assessment data regardless of payer and implement standardized patient assessment data elements (SPADEs). The SPADEs will assess cognitive function and mental status, special services, treatments and interventions, medical conditions and comorbidities, impairments, and social determinants of health to help improve coordination of care.

Finally, CMS used the proposed rule to refine the definition of “rehabilitation physician,” clarifying that IRFs are in the best position to determine what level of training or experience is sufficient to qualify.