ACR Responds to 2019 Benefit and Payment Parameters Proposed Rule


In a press release from November 28, 2017, the American College of Rheumatology (ACR) is urging the Centers for Medicare & Medicaid Services (CMS) to reconsider proposals reducing health exchange insurance coverage, affordability, and patient choice.

ACR officials said the response originates from the CMS 2019 Benefit and Payment Parameters proposed rule, which governs the state and federal health exchanges created by the Affordable Care Act.

“The ACR is committed to ensuring that Americans living with rheumatic diseases have access to high-value, high-quality healthcare. While we are pleased to see CMS is considering changes that would reduce drug costs and promote pricing transparency, we are deeply concerned about proposed changes that would make it more difficult for our patients to access and afford the care they need,” said ACR President David Daikh, MD, PhD.

Specifically, the organization opposes CMS’s proposal to permit states to select their own essential health benefit benchmark plans, maintaining the policy could create a “race to the bottom” wherein states will pursue the least acceptable coverage at the lowest cost, thereby restricting patient access to care. This flexibility may also result in states drastically limiting biologic drug coverage. Therefore, the ACR strongly recommended to the CMS that clinical decisions regarding treatments—especially those associated with medications—stay in the jurisdiction of providers. The rheumatology leaders stressed that treatment plans, as well as the authority to choose the use of one therapy over another, should not be determined by states or insurers.

The ACR also expressed serious concerns regarding CMS’s current plan to increase the rate review threshold from 10% to 15%, as this proposal would allow plans that have annual premium increases <15% to avoid the review process for unreasonable premium increases. The increase could result in more financial barriers for patients who are looking for affordable insurance coverage. Patients may also struggle to afford plan copayments and deductibles, because premium increases compound every year.

In addition, there are issues associated with the plan rate review designating Children’s Health Insurance Program’s buy-in programs as minimum essential coverage without first undergoing an application process. Because there is no guarantee that coverage under these programs would be equivalent, the ACR urged CMS to withdraw this proposal, or at least supply a reasoned analysis for the new standard and codify it into existing regulations.

“Adequate and affordable health insurance coverage is absolutely critical to managing chronic and complex rheumatic diseases and conditions,” Dr Daikh said. “We urge CMS to reconsider proposals that would severely reduce insurance coverage, access, and patient choice under the state and federal health exchanges. The ACR will continue to serve as a resource to CMS as it works to expand patient access to affordable care.”

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