2025 AEP Disruptions: Updates to The Inflation Reduction Act

[Duaine]

AIS Health Daily

May 22, 2024

Today's Featured Story

Part D Plans Get Ready for Potentially 'Messy' Rollout of M3P Program

by Lauren Flynn Kelly

For the first time ever, Medicare Part D beneficiaries in 2025 will have the opportunity to spread their prescription drug expenses over the course of the plan year. While Part D sponsors must offer the option to enrollees effective Jan. 1, 2025, plans face multiple considerations and tasks prior to then. One of their most immediate concerns, industry experts say, is factoring in potential administrative costs and/or financial losses associated with the new Medicare Prescription Payment Plan (M3P, as many are calling it) into bids due next month. Plans need to start preparing ASAP Created under the Inflation Reduction Act, the M3P requires stand-alone Prescription Drug Plans and Medicare Advantage Prescription Drug plans to give enrollees the option to pay out-of-pocket prescription drug costs in the form of capped monthly payments versus paying the full amount at the pharmacy. Program participants will pay $0 at the pharmacy but receive a monthly bill from their Part D carrier, which must reimburse the pharmacies in full. The first major decision Part D sponsors must make is whether to internally handle all the components (e.g., enrollment, invoicing, outreach) associated with the M3P, hire an outside company, or pursue a hybrid approach. And whatever approach they choose should be communicated to their pharmacy benefit manager (PBM) as soon as possible, if it hasn't been already, suggests Crescent Moore, Pharm.D., director of Part D/pharmacy with BluePeak Advisors, a Gallagher company. "Some of the PBMs have chosen to partner with an M3P vendor who's offering a solution. And then some PBMs are choosing to build out their own solution that they're offering to their health plan clients," Moore tells AIS Health. Then there are vendors that are offering a full suite of M3P solutions, she adds. Setting up M3P has 'many moving parts' "There's just so many moving parts to this, and it's a very short timeline," says Moore. "Everyone thinks about this going into effect 1/1/25. But you really need to be ready" before the Annual Election Period (AEP) starts in October. "Because when you start sending out your materials for the new plan year, you've got to include M3P information in there and folks will be calling in to potentially enroll in the program for 2025 during that October to December period." Other moving parts include identifying beneficiaries who are likely to benefit, enrolling beneficiaries, setting up a mechanism with the pharmacy so that claims exceeding the $600 threshold trigger a point-of-sale (POS) notification about eligibility, accurately calculating the monthly payment, sending invoices, and "providing all of that due diligence (e.g., grace periods) before you terminate someone from the M3P for lack of payments," points out Moore. Meanwhile, plans are concerned about the possibility that they won't get paid. CMS in its second draft guidance on the new program, released in February, included a "Notice of Failure to Pay" section, in which it advised sponsors to send notices to beneficiaries who have not paid their monthly billed amount. But if patients don't pay those bills, they must be met as plan losses. "There's going to be a percentage of members that don't pay or don't pay all of it," predicts Leslie Lotano-Saba, R.Ph., managing director with AArete. As a result, plans should be incorporating that kind of expectation into their plan costs for next year when they file bids. CMS clarified in the draft guidance that "only uncompensated unsettled balances" can be included as losses estimated in plan bids, and the agency said it will modify the Part D bid pricing tool to reflect projected losses associated with the M3P. [EXTERNAL LINK] - Gmail

 

[GoPokes]

Meanwhile, plans are concerned about the possibility that they won't get paid. CMS in its second draft guidance on the new program, released in February, included a "Notice of Failure to Pay" section, in which it advised sponsors to send notices to beneficiaries who have not paid their monthly billed amount. But if patients don't pay those bills, they must be met as plan losses. "There's going to be a percentage of members that don't pay or don't pay all of it," predicts Leslie Lotano-Saba, R.Ph., managing director with AArete. As a result, plans should be incorporating that kind of expectation into their plan costs for next year when they file bids. CMS clarified in the draft guidance that "only uncompensated unsettled balances" can be included as losses estimated in plan bids, and the agency said it will modify the Part D bid pricing tool to reflect projected losses associated with the M3P. [EXTERNAL LINK] - Gmail

This part made me laugh… there are a lot of beneficiaries that don't even open their mail.

I bet a few states won't even have a plan that is under the PDP benchmark premium, which is a bummer for the LIS crowd.

 

[Special Agent]

More like explaining why their premium jumped from $.50 to $50.00+

I wonder how the benchmark amount for LIS will play in to this.In Florida the benchmark for 2024 is 38.00 so there will have to be part D plans available for premiums under the 2025 benchmark

You quoted me - I doubt my PDP book is massive but it is over 750 active PDPs. Certainly not a small book of PDPs.

Wow 750 that will be tough since it has to be dealt with in AEP at least with MAPD their is OEP to relieve some of the pressure .I wish you well

This part made me laugh… there are a lot of beneficiaries that don't even open their mail.

I bet a few states won't even have a plan that is under the PDP benchmark premium, which is a bummer for the LIS crowd.

I believe there has to be plans below the benchmark in each state.In Florida for 2024 the bench mark is aprox. 38.00 so i am guessing that will increase to maybe 50.00 for 2025 so that is possibly going to be the lowest part D premium available in Fl. for 2025

 

[kgmom219]

AIS Health Daily

May 22, 2024

Today's Featured Story

Part D Plans Get Ready for Potentially 'Messy' Rollout of M3P Program

by Lauren Flynn Kelly

For the first time ever, Medicare Part D beneficiaries in 2025 will have the opportunity to spread their prescription drug expenses over the course of the plan year. While Part D sponsors must offer the option to enrollees effective Jan. 1, 2025, plans face multiple considerations and tasks prior to then. One of their most immediate concerns, industry experts say, is factoring in potential administrative costs and/or financial losses associated with the new Medicare Prescription Payment Plan (M3P, as many are calling it) into bids due next month. Plans need to start preparing ASAP Created under the Inflation Reduction Act, the M3P requires stand-alone Prescription Drug Plans and Medicare Advantage Prescription Drug plans to give enrollees the option to pay out-of-pocket prescription drug costs in the form of capped monthly payments versus paying the full amount at the pharmacy. Program participants will pay $0 at the pharmacy but receive a monthly bill from their Part D carrier, which must reimburse the pharmacies in full. The first major decision Part D sponsors must make is whether to internally handle all the components (e.g., enrollment, invoicing, outreach) associated with the M3P, hire an outside company, or pursue a hybrid approach. And whatever approach they choose should be communicated to their pharmacy benefit manager (PBM) as soon as possible, if it hasn't been already, suggests Crescent Moore, Pharm.D., director of Part D/pharmacy with BluePeak Advisors, a Gallagher company. "Some of the PBMs have chosen to partner with an M3P vendor who's offering a solution. And then some PBMs are choosing to build out their own solution that they're offering to their health plan clients," Moore tells AIS Health. Then there are vendors that are offering a full suite of M3P solutions, she adds. Setting up M3P has 'many moving parts' "There's just so many moving parts to this, and it's a very short timeline," says Moore. "Everyone thinks about this going into effect 1/1/25. But you really need to be ready" before the Annual Election Period (AEP) starts in October. "Because when you start sending out your materials for the new plan year, you've got to include M3P information in there and folks will be calling in to potentially enroll in the program for 2025 during that October to December period." Other moving parts include identifying beneficiaries who are likely to benefit, enrolling beneficiaries, setting up a mechanism with the pharmacy so that claims exceeding the $600 threshold trigger a point-of-sale (POS) notification about eligibility, accurately calculating the monthly payment, sending invoices, and "providing all of that due diligence (e.g., grace periods) before you terminate someone from the M3P for lack of payments," points out Moore. Meanwhile, plans are concerned about the possibility that they won't get paid. CMS in its second draft guidance on the new program, released in February, included a "Notice of Failure to Pay" section, in which it advised sponsors to send notices to beneficiaries who have not paid their monthly billed amount. But if patients don't pay those bills, they must be met as plan losses. "There's going to be a percentage of members that don't pay or don't pay all of it," predicts Leslie Lotano-Saba, R.Ph., managing director with AArete. As a result, plans should be incorporating that kind of expectation into their plan costs for next year when they file bids. CMS clarified in the draft guidance that "only uncompensated unsettled balances" can be included as losses estimated in plan bids, and the agency said it will modify the Part D bid pricing tool to reflect projected losses associated with the M3P. [EXTERNAL LINK] - Gmail

I'm a no. I lived through 2014 and I am not doing it again. If you think this is going to work, I've got a bridge to sell you. [EXTERNAL LINK] - Adobe Acrobat

 

[kgmom219]

Choose your poison.

I looked at the no-comp landscape leading up to 2014 and decided to go in a different direction because I thought it would be more secure.

It appears I may have misjudged . . .

I already have a hobby. Don't need another one.

Coulda, woulda, shoulda is not worth the time and effort. And you would absolutely hate Ocare.

 

[somarco]

you would absolutely hate Ocare.

I did then and have not changed my position.