Sellers Dorsey Digest
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SELLERS DORSEY DIGEST Issue 18 | January 21, 2021 NAVIGATION Summary of Key Updates On January 14, CMS Administrator Seema Verma submitted her resignation Federal Updates effective January 20, 2021. Verma reviewed administrative highlights On January 15, CMS finalized a rule including lowering premiums in the Medicare Advantage and Exchange on prior authorization and marketplaces, empowering patients by mandating price transparency, and increasing competition among providers. Liz Richter, who has worked at CMS information sharing which it first for 30 years, will serve as Acting Administrator (Twitter, January 14; Modern proposed on December 10, 2020. Healthcare, January 20). On January 12, HHS Secretary Alex Azar submitted his resignation effective at noon on January 20, 2021. Azar commented on the achievements over the course of the administration including those of Operation Warp Speed, the State Updates focus on facilitating patient-centered health care markets, protecting life and Democratic lawmakers in lives, and promoting independence over dependence in our safety-net Connecticut are proposing a tax on programs. He also condemned the recent attacks on the Capitol. Azar will be replaced by California Attorney General Xavier Becerra (Alex Azar, January carriers to help support and fund 12). the health insurance exchange and reduce costs for customers. Three drug makers filed separate federal lawsuits against HHS in an attempt to invalidate a recent HHS Office of General Counsel opinion that 340B discounts are applicable to contract pharmacies (Fierce Healthcare, January 13; Inside Health Policy, January 13). Private Sector Updates On January 15, CMS finalized a rule on prior authorization and information Accolade will acquire 2nd.MD, a sharing, which it first proposed on December 10, 2020. The final rule is largely telehealth start-up for $460 million. unchanged from the proposed version (CMS, January 15; CMS, January 15; Fierce Healthcare, January 15; Modern Healthcare, January 15). 2nd.MD, which went public last year, helps patients get expert medical From January 12 through January 19, CMS approved one Section 1135 waiver, one 1115 waiver, nine Section 1915(c) Appendix K waivers, and nine SPAs, opinions virtually. three of which are time-limited, COVID-19 disaster relief SPAs. Sellers Dorsey Updates Sellers Dorsey is proud to be a Major Sponsor of the upcoming Texas State of Reform Virtual Health Policy Conference, held on February 4. If you are a client and have questions, we advise you to consult with your Sellers Dorsey account or project contact. If you are not currently working with Sellers Dorsey, please email [email protected]. Subscribe to this newsletter here: www.sellersdorsey.com/about/newsletter. 2 Federal Updates News • On January 15, CMS released two tools intended to assist states’ operational planning efforts for returning state Medicaid programs to standard operations following the expiration of the public health emergency (PHE). These tools build on the State Health Official Letter CMS released on December 22, 2020. One tool is specific to eligibility actions, while the other covers more general program considerations. As noted in a December 22 letter, states are not required to submit these documents to CMS for approval but must make them available upon request (CMS, January 15). Federal Regulations • On January 15, CMS finalized a rule on prior authorization and information sharing, which it first proposed on December 10, 2020. The public comment period for the rule was just 22 days, which MACPAC and industry groups argued was insufficient given the scope of the changes. With the exception of some specific application program interface (API) requirements, the final rule is largely unchanged from the proposed version. Medicare Advantage plans are not subject to these new regulations. Key provisions include: o Requirement for impacted payers to include information about a patient’s claims, encounters, and pending and active prior authorization decisions in the Patient Access API. o Requirement for impacted payers to build a Provider Access API for payer-to-payer and payer-to- provider data sharing. o Requirement to facilitate a more efficient and transparent prior authorization process that will allow providers to: . Look up prior authorization requirements within a payer’s API. Submit and receive electronic prior authorization requests. Receive denial reasons on prior authorization requests. Send prior authorization decisions within 72 hours for urgent requests and 7 calendar days for standard requests (not including Qualified Health Plans). o Requirement for payers to publicly report prior authorization metrics (CMS, January 15; CMS, January 15; Fierce Healthcare, January 15; Modern Healthcare, January 15). • On January 8, HHS finalized a regulation first proposed on November 4, 2020, overhauling the agency’s requirements for reviewing its own existing regulations, dubbed the “Securing Updated and Necessary Statutory Evaluations Timely (SUNSET)” rule. Under this rule, any HHS regulation will cease to be effective after 10 years unless HHS “performs a plenary assessment of the regulation and a more detailed review of those regulations that have a significant economic impact upon a substantial number of small entities.” In a change from the proposed rule, the final rule gives HHS five years to complete its review of existing regulations that are more than 10 years old. Some rules, like Medicare payment rules, are exempt. Industry groups argue this review process could lead to considerable provider confusion (HHS, January 8; HHS, January 8; Fierce Healthcare, January 8). Federal Legislation • The Consolidated Appropriations Act 2021 contains several provisions focused on government spending. However, Congress also included requirements to strengthen mental health parity in a managed care environment, particularly non-quantitative treatment limitations (NQTLs) through the Strengthening Behavioral Health Parity Act (HR 7539). NQTLs include a range of managed care practices, including medical necessity criteria and clinical coverage guideline development, utilization management, provider network recruitment, reimbursement rate methodologies, and other practices that constitute "a limit on If you are a client and have questions, we advise you to consult with your Sellers Dorsey account or project contact. If you are not currently working with Sellers Dorsey, please email [email protected]. Subscribe to this newsletter here: www.sellersdorsey.com/about/newsletter. 3 the scope or duration of services." The provisions will largely impact health plans that are now subject to additional oversight requirements by the Departments of Labor and HHS. Of note, Medicaid managed care organizations do not have to follow the new compliance requirements if the plans comply with parity requirements in CMS Medicaid regulations and the Mental Health Parity Act (American Health Law Association, January 15). o In the January 7 issue of Sellers Dorsey Digest, we highlighted the spending provisions under the Consolidated Appropriations Act. The Biden-Harris Administration • On January 15, President Joe Biden and Vice President Kamala Harris announced eight additional appointees for the White House COVID-19 Response Team. All appointees will join the team during the Biden-Harris transition, with no member having previously worked for the Trump administration. This team will implement a cohesive COVID-19 response strategy that includes vaccinating Americans efficiently, increasing testing across the country, and changing the trajectory of the pandemic. Appointees for the team are as follows: o Amy Chang, Policy Advisor o Abbe Gluck, Special Counsel o David Kessler, Chief Science Officer of COVID-19 Response o Rosa Po, COVID-19 Response Team Deputy Chief of Staff o Andy Slavitt, Senior Advisor to the COVID-19 Response Coordinator o Vidur Sharma, Policy Advisor for Testing o Ben Wakana, Deputy Director of Strategic Communications and Engagement o B. Cameron Webb, Senior Policy Advisor for COVID-19 Equity (Build Back Better, January 15). • On January 14, President Biden proposed the American Relief Plan, a $1.9 trillion relief package that includes $400 billion to fight the COVID-19 pandemic, including the following COVID-19 specific aid for: o National vaccine program ($20 billion) – to offer free shots for all US residents and establish community vaccination centers nationwide and mobile units in rural communities. Biden will also work with Congress to expand the federal matching rate to 100% for vaccination of all Medicaid enrollees. o COVID-19 testing ($50 billion) – to fund purchase of rapid tests, expand lab capacity, and assist local governments in creating testing plans. o Personal protective equipment ($30 billion) – to purchase supplies such as ventilators and personal protective equipment. o Public health jobs (100,000 jobs) – to fund jobs like vaccine outreach and contact tracing. o Federal wage increase ($15/hour) – to increase the federal minimum wage to $15 per hour. This is more than double the current $7.25 rate. o Local aid ($350 billion) – to allocate funds for state and local governments to bridge budget shortfalls. o Stimulus checks ($1,400/ person) – make direct payments to Americans. o Emergency paid leave – extend emergency paid leave to 106 million Americans. o Small business loans ($15 billion) – extend directly to small businesses plus $35 billion of government funds into low-interest loans