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CARA Act Implementation Gives Medicare Plans Additional Opportunities to Impact Drug Abuse

CARA Act Implementation Gives Medicare Plans Additional Opportunities To Impact Drug Abuse

In early March, the Centers for Medicare and Medicaid Services (CMS) announced its final rule related to policy changes for Medicare Advantage and Part D plans in 2019. One key point in the rule was implementation of aspects of the Comprehensive Addiction and Recovery Act of 2016 (CARA).Rx

The final rule’s CARA provision seeks to provide an additional tool to help Medicare Advantage (MA) and standalone Part D plans (PDP) to combat the growing opioid epidemic in America. The 2016 act required CMS to establish drug management programs in the Part D program. Under the rule, beginning in 2019, CMS will allow plans to limit at-risk Medicare beneficiaries’ access to coverage for frequently abused drugs. While the traditional Overutilization Monitoring System (OMS) program looks just at the Opioid class, the CARA drug management seeks to impact abuse of both Opioids and benzodiazepines.

The new rule essentially integrates the new CARA drug management programs, known as lock-in programs, with OMS. The current OMS program looks at overall threshold dosage along with a beneficiary’s use of multiple prescribers and multiple pharmacies for Opioid drugs. The CARA lock-in program will allow plans to craft limits to overall Opioid and benzodiazepine use. After appropriate case management intervention with providers, plans will be allowed to limit an at-risk beneficiary’s access to frequently abused drugs to selected prescribers and/or pharmacies. As with the OMS program, beneficiary-specific point-of-sale (POS) claim edits can also be used to address abuse. Beneficiaries will be allowed to submit prescriber and pharmacy preferences. Those with cancer, receiving palliative or end-of-life care, or in hospice or long-term care are exempted from such drug management programs.

The final rule also limits the ability of all dually eligible (duals) or low-income subsidy (LIS) beneficiaries to move (via a special enrollment period) from one MA plan to another to one change per calendar quarter in the first nine months of the calendar year. In an additional reform, those duals and LIS members who are identified as at-risk or potentially at-risk for prescription drug abuse under such drug management programs will have their ability to make plan changes further limited.

Plans need to take note that at-risk determinations, as well as prescriber and pharmacy lock-ins, will be subject to the appeals process. In essence, plans will need to process redeterminations in these cases with no initial coverage determinations tied to them.

Marc Ryan

Marc S. Ryan serves as MedHOK’s Chief Strategy and Compliance Officer. During his career, Marc has served a number of health plans in executive-level regulatory, compliance, business development, and operations roles. He has launched and operated plans with Medicare, Medicaid, Commercial and Exchange lines of business. Marc was the Secretary of Policy and Management and State Budget Director of Connecticut, where he oversaw all aspects of state budgeting and management. In this role, Marc created the state’s Medicaid and SCHIP managed care programs and oversaw its state employee and retiree health plans. He also created the state’s long-term care continuum program. Marc was nominated by then HHS Secretary Tommy Thompson to serve on a panel of state program experts to advise CMS on aspects of Medicare Part D implementation. He also was nominated by Florida’s Medicaid Secretary to serve on the state’s Medicaid Reform advisory panel.

Marc graduated cum laude from the Edmund A. Walsh School of Foreign Service at Georgetown University with a Bachelor of Science in Foreign Service. He received a Master of Public Administration, specializing in local government management and managed healthcare, from the University of New Haven. He was inducted into Sigma Beta Delta, a national honor society for business, management, and administration.

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