Formulary guidance and transparency from P&T to point of care

Lauren Flynn Kelly

Recent Posts

Radar On Market Access: New MA Rule Touches Protected Classes, Imposes Pricing Tool

Posted by Lauren Flynn Kelly on Dec 13, 2018

CMS on Nov. 26 issued a proposed rule making changes to the Medicare Advantage and Part D programs that would take effect in 2020. Key provisions in CMS’s latest drug pricing rule include a proposal to extend new flexibility to plan sponsors in the area of so-called six "protected" drug classes and the required implementation of a new electronic real-time benefit tool (RTBT), AIS Health reported.

Under CMS's Contract Year 2020 Medicare Advantage and Part D Drug Pricing Proposed Rule, plans would be able to:
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Topics: Industry Trends, Provider, Payer

Radar On Market Access: New Opioid Law Has Implications for MA, Medicaid Plans

Posted by Lauren Flynn Kelly on Nov 8, 2018

One year after the Trump administration declared the opioid crisis a public health emergency, the president signed The SUPPORT for Patients and Communities Act (H.R. 6), a bipartisan legislative package containing myriad provisions aimed at addressing the opioid epidemic. One of the main objectives of the law is to expand access to substance use disorder (SUD) treatment in Medicaid, AIS Health reported.

The new law contains certain flexibilities related to the IMD exclusion, which refers to a longstanding exception that prevented state Medicaid programs from using federal funds to cover care for patients in mental health and SUD residential treatment facilities with more than 16 beds. The primary change is that Section 5052 amends federal Medicaid law by giving state programs the option to cover care in certain IMDs, which may be otherwise not reimbursable for federal funds, for Medicaid beneficiaries aged 21 to 64 with an SUD for fiscal years 2019 to 2023. Through a state plan amendment, states may receive federal reimbursement for up to 30 total days of care in an IMD during a 12-month period for eligible individuals.

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Topics: Industry Trends, Payer, Provider