by Ellen Riker, Artemis Policy Group, Hemophilia Alliance Advocacy Consultant

As of January 1, 2024, CMS is requiring that all Medicare Part B claims submitted by HTCs for separately payable drugs purchased using the 340B Drug Discount Program include the “JG” modifier. All HTCs should update their billing systems to ensure that this modifier is included on their Medicare claims.

This requirement was included in the Inflation Reduction Act of 2022 (IRA), which established a Part B inflation rebate for drug manufacturers if their prices increased faster than the rate of inflation. The modifiers enable CMS to identify claims for 340B drugs, which are excluded from the calculation of the rebates.

Since 2018, the “TB” modifier has been required for Medicare Part B claims submitted by hospitals using 340B drugs under the Hospital Outpatient Prospective Payment System, but the requirement for non-hospital entities participating in 340B is new as of the start of the new year. CMS has provided two resources that HTCs will find useful:

• Medicare Learning Network Fact Sheet –
  https://www.cms.gov/files/document/mln4800856-medicare-part-b-inflation-rebate-guidance-use-340b-modifier.pdf
• FAQ document – https://www.cms.gov/medicare/medicare-fee-for-service-payment/hospitaloutpatientpps/downloads/billing-340b-modifiers-under-hospital-opps.pdf

Contact Zack Duffy (zack@hemoalliance.org), Director, Member & Community Relations, if you have any questions about this new requirement.

by Jeff Blake, Senior Vice President Member & Community Relations

2023 was another busy year for the Payer Team. We changed our name from the Payer Relations Team to Member and Community Relations Team (MCRs) and added two new staff members and one consultant. Our focus this year was to increase the number of HTC members that participate in our Hemophilia Alliance Network Services (HANS) PPO Network and enhance our relationships with the payer community. We now have 45 HTCs participating in our network and we have 14 in the pipeline at various stages of approval. Payers and our members are continuing to find value in HANS. Payer interest in Gene Therapy has led to HANS opportunities that also include factor units.

We developed and implemented HANS marketing material for payers and HTCs and we are enhancing our website with additional HANS information and material.

With 3.7 million units added this year, the MCR Team returned a total of 45.7 million bleeding disorder product units back to the HTC pharmacy programs since 2018. We want to continue to work with our members to significantly increase this number over the next few years. We are currently working on payer opportunities for our members that account for more than 88.5 million units.

We continue to work with State Medicaid Agencies and private payers to cover DDAVP intranasal spray and have had recent success with Nebraska Medicaid now covering the drug. Increasingly, we’ve been helping our members navigate access to care issues including Copay Accumulators, Copay Maximizers and Alternative Funding Models.

Thank you for your support in our Payer efforts! We look forward to working with you to make 2024 an even more successful year and working together to grow and strengthen your pharmacy programs.