On April 1, 2019, the Centers for Medicare and Medicaid Services (CMS) released the Announcement of Calendar Year (CY) 2020 Medicare Advantage Capitation Rates and Medicare Advantage and Part D Payment Policies and Final Call Letter (CY2020 Final Call Letter). This document provides rates and guidance for plans to submit their bids for the 2020 calendar year. The EnvisionRx Compliance team reviewed the CY2020 Final Call Letter to assess the operational changes required to comply. The key updates impact opioid utilization, formulary submission and Star Ratings.
Medicare Part D Opioid Utilization Policy
CMS underscored that the opioid interventions, as described in the CY2019 Final Call Letter and other published memos, continue to be an area of focus. With a 14% decrease in Medicare Part D beneficiary opioid usage despite a 34% enrollment increase between 2012 and 2017, CMS believes opioid-related initiatives, such as point-of-sale edits and drug management programs, are reducing the opioid demand and supply in Medicare Part D. CMS will utilize their experience with these interventions in 2019 and 2020 to evaluate the need for modifications or additional/alternative approaches. Plans should expect to see additional guidance and clarifications released by CMS.
One opioid-related change in the CY2020 Final Call Letter, is the recommendation that beneficiaries with sickle cell disease be excluded from the opioid safety edits. This is in addition to residents of long-term care facilities, beneficiaries in hospice care, those receiving palliative or end-of-life care, and beneficiaries being treated for active cancer-related pain.
Additionally, CMS is encouraging plan sponsors to increase access to naloxone, a drug used to treat opioid overdose in emergency situations. The agency is recommending inclusion of at least one naloxone product on plan formularies for CY2020, with a generic or select care (if available) tier placement. Plan designs that do not offer "appropriate" access to naloxone will not be approved by CMS.
CMS is encouraging plan sponsors to ensure authorizations for naloxone are in place for beneficiaries who are more susceptible to opioid-associated harm and also suggest more innovative approaches, such as patient-specific pharmacy messaging to alert pharmacists to provide naloxone to at-risk beneficiaries taking opioids in states that allow for standing naloxone orders. An example of an at-risk patient is a beneficiary with a claims history of less than 50 morphine milligram equivalents (MME) per day with concurrent benzodiazepine use. CMS also recommends targeted education of prescribers and enrollees on co-prescribing of naloxone to prevent accidental overdoses and to sensitively address the needs of persons with opioid use disorders.
EnvisionRx supports this decision and has included naloxone on proposed plan formularies, while providing plans the opportunity to opt out of the inclusion if desired.
CY2020 Formulary Submissions
CMS will provide plans with an Excluded Drug reference file for CY2020 in a format identical to the current Formulary Reference File (FRF). This updated file will reference RXCUIs* instead of national drug codes (NDCs), resulting in a streamlined and less burdensome process for CMS, plans and pharmacy benefit managers (PBMs).
EnvisionRx is updating its processes to reflect the new Excluded Drug file format.
Changes in 2020 Star Rating and Display Measures
In an effort to better measure the reliability of a plan’s Medical Plan Finder (MPF) advertised price, CMS is implementing several Star measure changes for 2020 and 2021. Beginning in 2020, Star measures will factor both how much and how often prescription drug event (PDE) prices exceed the price reflected on the MPF. Additionally, the claims affected by this measure will be expanded from 30-day fills to include claims with fills of 28-34, 60-62 or 90-100 days. The drug cost on the MPF will also be rounded to two decimal places for comparison to its PDE cost in certain instances.
Also beginning with the 2020 measurement for 2022 Star Ratings, the Appeals Auto-Forward and Appeals Upheld measures will be removed. However, CMS will continue to monitor plan sponsors’ processing of Part C and D appeals through program audits, annual reporting requirements, and other data and operations monitoring activities. Additionally, CMS will continue to monitor plans for potential access to care issues and require plans to correct non-compliance by issuing compliance actions (e.g., notices of non-compliance, warning letters, corrective action notices), as well as imposing enforcement actions (e.g., civil money penalties, intermediate sanctions or contract terminations) when serious or sustained non-compliance is identified.
CMS is also discontinuing the Transition Monitoring Program Analysis (TMPA) and Formulary Administration Analysis (FAA) Star measures for 2020, noting that there has been an improvement in formulary administration and transition practices. CMS does intend to continue to analyze formulary administration and transition procedures to ensure sponsors are meeting CMS requirements. However, the agency has not yet provided more information about how it intends to perform this analysis going forward.
EnvisionRx will continue to provide additional guidance for plan sponsors as more details on CY2020 plans are provided. You can also receive more specific information and learn how auditing can help you prepare for 2020 during our free Compliance Round Table webinar Thursday, May 30 at 2 p.m. ET.
* RXCUIs, known as RxNorm (normalized naming system for generic and branded drugs) concept unique identifiers, are the clinical drug components.