Earlier this month, the Centers for Medicare and Medicaid Services issued a policy change revising the Medicare Advantage Program (MAP) Part C regulations, and Prescription Drug Benefit program (Part D). 

Jean S. Goldstein

The ultimate goal of the new policy is to ensure that an individual’s treatment needs are met while improving the quality of care and providing greater choices to MA enrollees. The full text of the regulation can be found here, and an easy-to-read fact sheet on the final rule can be found here.

CMS estimates that the policy change will provide $295 million in savings a year for the Medicare program through 2023, which will result in lower premiums or additional benefits.

The policy also implements statutory provisions of the Comprehensive Addiction and Recovery Act of 2016 (CARA), which provides authority for Part D plans to establish drug management programs in 2019 to reduce the misuse or overdose of opioids. In line with this implementation, Part D plans will engage in case management to limit frequently abused drugs by at-risk beneficiaries. 

Of note, CMS has indicated that it will classify opioids and benzodiazepines as frequently abused drugs. Per the rule, to determine at-risk beneficiaries, CMS will use clinical guidelines, which are based on opioid use from multiple prescribers and/or multiple pharmacies. 

CMS will exempt beneficiaries who are being treated for active cancer-related pain, are receiving palliative or end-of-life care or are in hospice or long-term care from drug management programs. 

This appears to be a move in the right direction to address the opioid epidemic but has sparked some questions for us as Medicare secondary payer compliance providers. As you may recall, in November 2017, the California Workers’ Compensation Institute (CWCI) released a study documenting opioid use in workers’ compensation Medicare set-asides (WCMSAs), and the alarming results clearly laid out CMS’ default position on over-allocating opioids in WCMSAs. 

In what we believe was a response to the study and the MSP industry’s efforts to change the narrative on opioids in WCMSA allocations, CMS issued a statement indicating that:

CMS understands the concerns regarding the opioid crisis occurring in the United States. We are committed to ensuring the determination of workers’ compensation Medicare set-aside Arrangement (WCMSA) amounts are an adequate projection of claimant’s needs for future medical services and prescription drugs. CMS continually evaluates all policies and procedures related to WCMSA amounts. Any changes that Medicare pursues related to this issue will be reflected in our WCMSA amount review process.

However, to date, no changes have been implemented in the WCMSA review process as related to allocating opioids. This new policy change begs several questions: In 2019, when we begin to see change on the Medicare Part D side, will we also see a change in the methodology of WCMSA prescription allocations? Will opioids still be prescribed at the alarming frequencies and durations we currently see? Will CMS lessen its requirements for evidence of tapering and weaning as related to WCMSA allocations?

We are hopeful that with this policy change, and the new CMS Review Contractor, we will begin to see CMS implementing practical guidelines for WCMSAs that fall in line with its opioid abuse campaign. This is change that is desperately needed to protect injured individuals and continue to help curb opioid misuse.

Jean S. Goldstein is a CMS compliance manager and staff attorney for Medval. This blog post is republished here with permission.