Medicare to extend MA VBID model
The Centers for Medicare & Medicaid Services (CMS) announced Thursday it will extend the Medicare Advantage (MA) Value-Based Insurance Design (VBID) for calendar years 2025 through 2030. In addition, it will introduce changes to the model that will more fully address the health-related social needs of patients, advance health equity, and improve care coordination for patients with serious illness. Although information is scarce on the model update, the CMS Innovation Center offers an overview of the current model design in this fact sheet.
4 findings from latest report on the ACA
More than 40 million people are currently enrolled in marketplace or Medicaid expansion coverage related to the Affordable Care Act—the highest total on record, according to a report from the Office of the Assistant Secretary for Planning and Evaluation (ASPE).
Among the key highlights from the ASPE report:
- Marketplaces and Medicaid expansion programs created by the ACA have enrolled tens of millions of Americans since the programs launched in participating states in 2014.
- Six million consumers were enrolled in marketplace plans as of February 2023 (across all 50 states and the District of Columbia), and 18.8 million people (across 38 participating states and the District of Columbia) were newly enrolled in Medicaid via the ACA’s expansion of eligibility to adults as of September 2022.
- Two million individuals were enrolled in early 2023 in the ACA’s Basic Health Program option, and 4.6 million previously eligible adults gained coverage under the Medicaid expansion by September 2022 due to enhanced outreach, streamlined applications, and increased federal funding under the ACA.
- Across these coverage groups, a total of 40.2 million Americans were enrolled in coverage related to the ACA based on 2022 and early 2023 enrollment data, the highest total on record. This represents 9.3 million more people enrolled than in 2021 (a 30 percent increase) and 27.6 million more people enrolled than in 2014 (a 219 percent increase, or more than triple).
ACA’s preventive services coverage under threat: KFF looks at how many people take advantage of the benefit
The ACA requires most private health plans to cover many preventive services without any cost-sharing for their enrollees, but the future of the provision is in doubt: The U.S. District Court in the Northern District of Texas in September determined certain aspects of the requirement were unconstitutional and violated religious rights but has allowed the provision to remain in effect while it considers a remedy.
Meanwhile, a new Kaiser Family Foundation (KFF) analysis finds that roughly 100 million people received ACA-required preventive services with no patient cost-sharing in a typical year. Overall, about 60 percent of the 173 million people enrolled in private health coverage used at least one of the ACA’s no-cost preventive services in 2018 prior to the COVID-19 pandemic.
The most commonly received preventive services include vaccinations, well woman and well child visits, and screenings for heart disease, cervical cancer, diabetes, and breast cancer. COVID-19 vaccines are also provided at no cost to patients under the ACA’s preventive services requirement, though how many people will take them up in the future is uncertain, KFF noted in an announcement.
Women and children are more likely than men to have used at least one no-cost preventive service through their private insurance in 2018.” The analysis also looks at variations in the use of preventive services in the large group, small group, and individual markets.
HHS offers initial guidance for Medicare drug price negotiations
The U.S. Department of Health and Human Services (HHS), through the Centers for Medicare & Medicaid Services (CMS), has released initial guidance on key elements of the new Medicare Drug Price Negotiation Program for 2026, the first year the negotiated prices will apply.
“Drug price negotiation is a critical piece of how this historic law improves the Medicare program,” said CMS Administrator Chiquita Brooks-LaSure in the announcement. “By considering factors such as clinical benefit and unmet medical need, drug price negotiation intends to increase access to innovative treatments for people with Medicare.”
This initial guidance is one of a number of steps CMS laid out in the Medicare Drug Price Negotiation Program timeline for the first year of negotiation. The initial program guidance details the requirements and procedures for implementing the new Negotiation Program for the first set of negotiations, which will occur during 2023 and 2024 and result in prices effective in 2026. Key dates for implementation include:
- By September 1, 2023, CMS will publish the first 10 Medicare Part D drugs selected for initial price applicability year 2026 under the Medicare Drug Price Negotiation Program.
- The negotiated maximum fair prices for these drugs will be published by September 1, 2024 and prices will be in effect starting January 1, 2026.
- In future years, CMS will select for negotiation up to 15 more Part D drugs for 2027, up to 15 more Part B or Part D drugs for 2028, and up to 20 more Part B or Part D drugs for each year after that, as outlined in the Inflation Reduction Act.
In response to the guidance, Avalere Principal Mike Ciarametaro said the information leaves many open questions regarding how CMS will determine the negotiated price. “The biggest takeaways include a broad definition of therapeutic alternatives, a narrow definition of unmet need, and a primary focus on the Medicare population,” Ciarametaro said.