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CMS Issues CARA Drug Management Program Guide

CMS Issues CARA Drug Management Program Guide

In an earlier blog found here, we told you about the tremendous opportunity provided by the Comprehensive Addiction and Recovery Act (CARA) (regulations published in April) for plans to curb drug abuse via a Drug Management Program (DMP). Last week, the Centers for Medicare and Medicaid Services (CMS) issued its comprehensive policy guidance for plans to implement and enact such programs (guide found here).

CMS notes that although DMPs are voluntary under CARA, most sponsors are implementing the programs in 2019. In addition, the Support for Patients and Communities Act passed by Congress in late October requires all Part D sponsors to have a DMP beginning in 2022.

As we said in our previous blog, the CARA DMP is run in conjunction with current Overutilization Monitoring (OMS) for Opioids. Plans are required to communicate in writing with beneficiaries for whom they intend to limit access to frequently abused drugs (FADs). CMS has developed standardized notices to be sent to beneficiaries and these notices will be required to be used by plans. These forms will shortly be approved by the Office of Management and Budget (OMB). In the meantime, plans should begin aspects of the DMP program pending notice approval and will have 90 days following the release of the standardized notices to fully implement aspects of their programs requiring the notices.

CMS will provide plans with quarterly Overutilization Monitoring System (OMS) reports of potential at-risk beneficiaries. Plans can identify at-risk members by applying the CMS criteria or broader plan criteria. CMS notes that a DMP program includes both coverage restrictions/limitations and case management of impacted individuals and that various studies and data conclude that case management interventions have the greatest impact on abuse and over-utilization.

The policy guidance will serve as the governing document for plan programs.  Some key areas covered include:

  • Defining at-risk and potentially at-risk individuals
  • Drugs covered in a DMP
  • Current OMS guidelines and reports and exempted members
  • Framework of a DMP, including notification and case management
  • Drug limitation/restrictions

Recently, too, CMS issued its 2019 OMS updates.  There are numerous changes that impact plans.  We are digesting those changes and will blog about those changes next week.

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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