CMS Raises Medicare Advantage Payments, Tweaks Opioid Language for Patients With Pain

CMS, on Monday, finalized its 2019 Medicare Advantage rates, raising payments it pays to insurers, and also made changes to a final rule aimed at curbing opioid misuse and abuse by Medicare beneficiaries.

Payments to Medicare Advantage plans will rise an average of 3.4%, and with another 3.1% adjustment coming from a change in risk scores (which are a measure of the sickness or health of the population served) the payment increase could be as high as 6.5%.

In advance notice of the rate changes, CMS has forecasted an increase of 1.84%, not including any risk-scoring adjustments.

In a call with reporters announcing the changes, led by CMS Administrator Seema Verma, the agency said it was changing how it used encounter data (created by healthcare providers during visits with patients) to set risk scores, by boosting the percentage of such data to 25%, up from 15%. The remaining 75% would come from Medicare fee-for-service data. The agency is also adding additional mental health, substance use disorder, and chronic kidney disease conditions to its risk adjustment model.

CMS also said it finalized a reduction in the maximum amount that low-income beneficiaries pay for biosimilars, saving the agency about $10 million. CMS also said it was taking other actions to lower the cost of prescription drugs for beneficiaries but did not give an estimate.

In other changes, CMS said certain low-cost generic drugs could be substituted onto plan formularies at any point during the year, instead of waiting for open enrollment periods. It removed the requirement that certain Part D plans have to “meaningfully differ” from each other, making more plan options available. It also said it clarified the “any willing provider” requirement, to increase the number of pharmacy options that beneficiaries have.

In an effort to combat opioid substance use disorder, CMS is allowing Medicare drug benefit plans to require beneficiaries at risk of addiction or overuse to use only selected prescribers or pharmacies for opioid prescriptions. In addition, the agency said it was expanding its overutilization monitoring system, which it said has "already significantly reduced the number of high risk beneficiaries." These beneficiaries would require care coordination.

But CMS said it did not expect these actions to apply to patients in long-term care facilities, in hospice care or those receiving palliative or end-of-life care, or patients being treated for active cancer-related pain

It also specifically called out acute pain regarding a limit of 7 days’ supply of opioids for new prescriptions, and indicated how it expected pharmacy plans, pharmacists, and providers to coordinate care for other patients requiring larger amounts of opioids for chronic pain.

An HHS report last year from their inspector general’s office concluded that opioid use was an issue in Medicare Part D, with 1 out of every 3 beneficiaries receiving a prescription opioid and 500,000 receiving an average daily morphine equivalent dose (MED) of 120 mg for at least 3 months a year.

MED is a measure that equates all the various opioids and strengths into 1 standard value.

On Regulations.gov, many of the more than 600 comments CMS received about the proposal were from chronic pain patients who said they took their medicine responsibly and that opioids were necessary for them to function.