CMS Releases a Second Rule to Provide Flexibility During COVID Emergency
By Ellen Riker

On April 30, 2020, the Centers for Medicare and Medicaid Services (CMS) issued a second Interim Final Rule providing significant flexibility in Medicare coverage and payment for hospital and physician services and waivers on other Medicare and Medicaid requirements during the COVID emergency. Most of the changes in the rule are retroactively effective for services provided as of March 1, 2020 and will continue through the government declared public health emergency or December 31, 2020. A summary of the rule can be found here and a one-pager with details on the telemedicine changes made by both rules may be found here.

While coverage for telephone only services (CPT Codes 99441-99443) was included in the Medicare Interim Final Rule released on March 30, 2020, in this rule the reimbursement rates are being increased to mirror the level 2 – 4 office/outpatient evaluation and management services for established patients. See the summary for more information.

The Alliance submitted a comment letter to CMS on the first Interim Final Rule, published on March 30, 2020 and summarized in earlier Newsletter articles. The letter supports the expansion of telemedicine coverage and the proposal for the home health benefit, which would support bleeding disorders patients who need assistance in self-administering their treatments in their homes.

For more information, please contact me at eriker@artemispolicygroup.com.

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CMS Releases Rule Reopening Door for Accumulator Adjustor Programs
By Johanna Gray

On May 7th, the Centers for Medicare and Medicaid Services (CMS) released the final 2021 Notice of Benefit and Payment Parameters Rule (NBPP), an annual rule that sets policies for private insurance plans. In recent years, CMS has released conflicting information about whether and when accumulator adjustor programs are permitted in private insurance plans (where insurers or PBMs say that manufacturer co-pay assistance does not count towards a person’s out-of-pocket maximum) and unfortunately, the final rule for 2021 reopens the door for these programs.

First, a bit of history: when accumulator adjustor programs first popped up in 2015, several groups started an advocacy campaign to ask CMS to prohibit these harmful programs. After years of education and advocacy, in the 2020 NBPP, CMS indicated that plans could implement accumulator adjustor programs only for brand name drugs when there is a generic alternative. This was very exciting – and welcome! – news for our community. Since there are no generic versions of bleeding disorders treatments, this rule essentially prohibited accumulator adjustor programs for our patients. Then, last summer, CMS released a reinterpretation of the policy, due to a potential conflict with IRS rules surrounding high-deductible health plans and health savings accounts and said that it would clarify the policy in its rule this year.

Unfortunately, in the 2021 rule, CMS says that accumulator adjustor programs are allowed for all drugs, even if there is not a generic equivalent. The Agency does not require plans to implement these programs but provides insurers with discretion over whether to allow co-pay assistance to count towards the out-of-pocket max or not. CMS also urges insurers to be transparent about whether they have implemented an accumulator adjustor program, which would at least help mitigate the surprise.

I hate to be the bearer of bad news from DC but note one positive fact: as we consider additional federal advocacy strategies, advocates are continuing state-level efforts, since states can prohibit accumulator programs for insurance plans they regulate. Several states have done so (based on advocacy from the bleeding disorders community) and others are considering making this change. In the meantime, please do let us know if you have any patients experiencing this issue. We work closely with NHF, a national leader on this issue, and together we have been able to assist many families.