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Congress Urges Tri-Agencies Action on EHBs
Members of Congress have written to the Departments of Health and Human Services, Labor, and Treasury (tri-agencies) urging them to issue the promised rulemaking on copay maximizers. The anticipated rule would align the 2025 Notice of Benefit and Payment Parameters (NBPP) that covered “drugs in excess of the state benchmark plan” as Essential Health Benefits and subject to patient cost sharing protections and prohibitions on annual and lifetime limits to self-funded plans.
According to the letter led by Reps. Buddy Carter (R-GA-01) and Nanette Barragan (D-CA-44), health plans designate select covered drugs as “non-Essential Health Benefits,” even when those drugs are critical to the patient’s health. Insurers label these medications as “non-essential” to avoid statutory limits on enrollee cost-sharing. The health plans set copays at levels that allow them to capture all available copay assistance dollars, and then refuse to count any of that copay assistance toward the patient’s deductible and out-of-pocket maximum.
The 2025 NBPP included a provision that will effectively ban the use of copay maximizers by individual and small group plans, but unfortunately does not extend to large group and self-insured plans. In April, the tri-agencies claimed they would extend the rulemaking to align standards across all insurance markets. However, tri-agencies have yet to issue the promised rule, hence prompting congressional action.
Another Doc Fix Introduced by Congress’s MDs
Rep. Greg Murphy, M.D. (R-NC-03) and other physician colleagues in the House of Representatives introduced the bipartisan Medicare Patient Access and Practice Stabilization Act (H.R.10073), which would eliminate the 2.8% conversion factor cut to the Medicare Physician Fee Schedule and provide a 1/2 Medicare Economic Index (MEI) update for 2025. CSRO is recognized as a supporting organization of this measure.
This summer, a CMS proposed rule included a reduction in Medicare reimbursement for physician services by 2.8%, beginning on January 1, 2025. If this cut goes into effect, physicians will face a total 6.4% cut due to the additional CMS estimated increase in practice expenses for 2025 at 3.6%. CSRO has been a vocal advocate for eliminating the 2.8% conversion rate cut and for finding long term solutions that do not inflict financial hardship on physicians. According to the AMA, Medicare reimbursement for physician services has declined 29% from 2001 to 2024, when adjusted for inflation.
CSRO Warns of Potential Harms in Reducing FDA Oversight of Biosimilars
Sen. Mike Lee (R-UT) has introduced legislation that aims to increase access to cost effective biosimilars by eliminating the FDA’s interchangeability determination process and corresponding switching studies. However, in a letter to congressional leadership, CSRO warned that the Biosimilar Red Tape Elimination Act (S.2305) may have unintended consequences for patients and providers. CSRO believes it is important that the FDA continues to have unique standards for interchangeability designation and does not allow all biosimilars to be deemed interchangeable without additional evaluation.
The Coalition believes removing the interchangeability designation would exacerbate existing challenges posed by payer practices in the form of non-medical switching, step-therapy, prior authorization, and other utilization management tactics. Unique standards for granting interchangeability status, though sometimes ignored by payers, provide a necessary safeguard that helps guide clinical decision-making and protects patients from the potentially harmful effects of inappropriate drug switching.
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