CMS Proposes Big Changes for Medicaid Waivers, Part D Drug Costs

November 30th, 2018

By Jill Drachenberg, Editor, Relias Media

As 2018 nears its close, the Centers for Medicare & Medicaid Services (CMS) is proposing some big changes for the coming year.

CMS Administrator Seema Verma this week described the proposal for new types of section 1332 State Relief and Empowerment Waivers aimed at giving states greater control over Medicaid plans. Verma laid out the following four waivers at the States and Nation Policy Summit of the American Legislative Exchange Council:

• Account-based Subsidies — similar to health savings accounts — would designate public subsidies to consumer-directed accounts to be used for paying insurance premiums, copays, and other out-of-pocket expenses. Individual and employer contributions also can fund the accounts. Individuals are in control of their accounts. “This approach maximizes consumer choice and engagement, giving people flexibility to make smarter decisions with their health care dollars because they directly retain the benefit of any unspent funds from the account,” according to CMS.
• State-specific Premium Assistance waivers would allow states to create their own subsidy programs to better meet the needs of the specific populations, including expanding eligibility criteria.
• Adjusted Plan Options waiver could be used in conjunction with Account-based Subsidies by giving financial assistance to individuals to purchase health insurance from an expanded list of options. States could contribute these subsidies to individual accounts, allowing individuals to purchase insurance and cover out-of-pocket expenses.
• Risk Stabilization Strategies can “address the costs of high risk individuals to reduce premiums in the market for everyone,” according to the CMS announcement.

Also announced this week was the CMS plan to “strengthen and modernize” Medicare Part C and D programs by giving them more negotiating power to lower drug costs by contract year 2020. Plans include eliminating the pharmacy gag clause that prevented pharmacists from informing patients of a lower cash payment option outside of Part D; more flexibility to manage six “protected class” drugs (antidepressants, antipsychotics, anticonvulsants, immunosuppressants, antiretrovirals, and antineoplastics) and negotiate greater discounts; and requiring drug pricing information in the Part D Explanation of Benefits. The proposed Part D rule is available in the Federal Register, and the comment period closes Jan. 25, 2019.

More information on coordination of care and benefits for Medicare and Medicaid patients can be found in upcoming issues of Hospital Case Management and Case Management Advisor.