ACA Prescription Coverage Could See Big Changes in 2016 From Proposed Rules, Supreme Court Case
Prescription drug coverage in the Affordable Care Act (ACA) marketplace could undergo significant changes in 2016 due to new formulary oversight and review requirements set forth in the Centers for Medicare and Medicaid Services (CMS) proposed rule, as well as a forthcoming proposed rule on nondiscrimination in marketplace plans. Meanwhile, the outcome of the King v. Burwell decision that is now under consideration by the Supreme Court could change the landscape of the health insurance marketplaces for 2016 and beyond.
The Affordable Care Act (ACA) includes provisions to protect beneficiaries against discrimination in the issuance of private insurance plans in the United States. In recent years, CMS has found that some formulary benefit designs have discriminated against individuals with HIV/AIDS and other chronic conditions by placing all medications for treating these conditions in the highest cost-sharing tier. CMS has also expressed concern that plans might be excluding certain individuals from receiving appropriate access to health care benefits by limiting coverage to certain medications for pediatric conditions only or limiting access to extended release medications.
To date, CMS has not issued guidance to states that review insurance plans on discrimination issues and therefore assessing discrimination has been difficult. A proposed rule, which will be issued soon by the Department of Health and Human Services (HHS) Office of Civil Rights, is expected to provide guidance that would allow plans to develop benefit structures that guard against discrimination in the areas of race, national origin, sex (including gender identity), disability and age. The scope of this proposed rule could be based upon feedback CMS received in from a 2013 request for information (RFI) which sought insight from the public on examples and areas of discrimination in health care.
While AMCP did not comment on the RFI, it communicated with HHS and CMS support to ensuring access to safe and appropriate medications for individuals who need coverage. This access must be supported by evidence-based guidance to ensure appropriateness for each individual. Access must also be balanced with coverage is affordable to individuals, public and private payers, and the government. AMCP will apprise members of the release of this proposed rule and the impact on AMCP members.
For a review of 2016 formulary issues and the new guidance and forthcoming proposed rule, AMCP members may access an archive of a May 13, 2015 webinar called "Are You Up-to-Date on Formulary & Prescription Drug Benefit Coverage in Federally-Facilitated Marketplaces Beginning in 2016?"
In a related issue, the outcome of the King v. Burwell decision that is now under consideration by the Supreme Court will determine whether the ACA allows individuals in 34 states that run federally-facilitated marketplaces to be eligible for federal subsidies. CMS has suggested several options if the Supreme Court nullifies the ability of individuals in these states to receive subsidies, including exchange lease agreements between CMS and states. Insurers also have suggested that they will need more time to adjust benefit structures to accommodate the need for potentially higher premiums. AMCP will host a members-only webinar called, Supreme Court Decision: What’s Next, in conjunction with Avalere on Wednesday, June 3, 2015 from 2-3 pm. Members may register for this webinar on AMCP’s Webinar Calendar of Events by clicking here.