Last week, CMS issued its final rule for Medicare Advantage (MA) and Part D plans, updating key policies for contract year (CY) 2024. The final policies aim to meaningfully improve utilization management (UM), including prior authorizations, and marketing of MA and Part D plans to seniors.

As outlined in a fact sheet, the rule clarifies clinical criteria guidelines to ensure people with MA receive access to the same medically necessary care they would receive in Traditional Medicare, and streamlines prior authorization requirements, including adding continuity of care requirements and reducing disruptions for beneficiaries. Also of importance, the fact sheet highlights finalized policies that would address confusing and potentially misleading marketing, while also ensuring potential enrollees have accurate and necessary information to make coverage choices that best meet their needs.

While CMS declined to address step therapy as part of its regulations, the Agency committed to monitoring step therapy and considering stakeholder recommendations for future rulemaking.

On Thursday, April 27, WPS Government Health Administrators, along with the six other Part B Medicare Administrative Contractors (MACs), will host a multi-jurisdictional Carrier Advisory Committee (CAC) meeting to discuss the evidence relating to trigger point injections (TPI).

Rheumatologists perform TPI to address myofascial pain, most commonly in the lower neck and upper back. CSRO is coordinating with rheumatologists who have an interest in this service to provide feedback throughout the process, as appropriate, and if you have any practical anecdotes about how this treatment has been beneficial to your patients, email info@csro.info.

Registration to attend the meeting is required and is available via this link, and an agenda, list of literature, and key questions, are available here.

Rheumatologists and other specialty physicians responded to a request for input (RFI) from the Physician-Focused Payment Model Technical Advisory Committee (PTAC) highlighting the value of specialty medical care and raising concerns about the challenges specialists face in establishing and joining alternative payment models (APMs).

The coalition of 16 medical specialty societies highlighted efforts to establish stand-alone and “nested” models of care delivery and payment, some of which were recommended by PTAC, only to be turned away by the Centers for Medicare and Medicaid Services (CMS) Innovation Center. The specialists noted that this essentially blocks them from meaningfully participating in the APM track of CMS’ Quality Payment Program (QPP), thus limiting their QPP engagement to the Merit-Based Incentive Payment System (MIPS), where incentives have evaporated. The groups also urged the public release of data on specialists participation in APMs, including Accountable Care Organizations (ACOs).

Join CSRO to meet with Federal policymakers to highlight legislation of interest to the rheumatology community! Rheumatologists around the country are invited to join us on July 13 for live conversations with health care leaders from the U.S. Senate and U.S. House of Representatives.

Your participation helps ensure that the issues impacting you and your practice are shared with members of Congress. Register now and hold the date on your calendar – specific meetings will be confirmed in June, and the schedule will be shared with attendees in the weeks leading up to the event.

The Arthritis Foundation would like to better understand the needs of rheumatology health care providers (HCPs) and their patients to help identify ways they can support you, your office, and your patients. Please consider completing this 3-minute survey: Arthritis Foundation HCP Survey.

CSRO's Vice President of Advocacy & Government Affairs, Dr. Madelaine Feldman, reflects on the importance of educating physicians about the impact pharmacy benefit managers (PBMs) and formulary construction have on patients and practices, and turning more of the rheumatology community into "rheums for action".

Read more in the latest edition of Rheum for Action, CSRO's advocacy column produced in partnership with Rheumatology News (PDF available here).

What's Happening in the States

CSRO tracks legislative activity relevant to the rheumatology community and their patients. Check out the list below to see the status of CSRO priority bills from the past two weeks, and click here to view a full status report.

Be sure to check out our interactive legislative map tool for additional details.

ALASKA

Rebate Pass Through

• SB 124: Introduced and referred to Labor and Commerce committee

White Bagging

• SB 121: Introduced and referred to Labor and Commerce committee

ARKANSAS

Biomarker Testing

• HB 1121: Signed by the Governor

Gold Card

• HB 1271: Transmitted to the Governor’s office
• SB 143: Withdrawn

Rebate Pass Through

• HB 1481: Signed by the Governor

CALIFORNIA

Rebate Pass Through

• SB 873: Set for hearing 4/19/23

COLORADO

Accumulators

• SB 195: Amended version referred to Senate Appropriations committee

Step Therapy

• HB 1183: Passed 3^rd reading in the Senate 

GEORGIA

Biomarker Testing

• HB 85: Transmitted to the Governor

White Bagging

• HB 417: Re-committed to House committee

FLORIDA

Accumulators

• SB 46: Approved by Banking and Insurance committee, re-referred to Health Policy committee

INDIANA

Rebate Pass Through

• SB 8: Approved by House, returned to Senate with amendments

LOUISIANA

Biomarker Testing

• SB 104: Introduced and referred to Insurance committee

MARYLAND

Biomarker Testing

• SB 805: Transmitted to the Governor
• HB 1217: Transmitted to the Governor

MISSOURI

Gold Card

• HB 1045: Public hearing completed

White Bagging

• HB 198: Reported do pass by committee
• SB 26: Reported do pass by committee 

MONTANA

Gold Card

• SB 380: Committee amends and bill scheduled for 3^rd reading

NEVADA

Step Therapy

• SB 194: Reported do pass as amended by committee

NEW MEXICO

Accumulators

• SB 51: Signed by the Governor

Biomarker Testing

• HB 73: Signed by the Governor

NORTH DAKOTA

Accumulators

• HB 1413: House does not concur with Senate amendments, conference committee appointed

Non-medical Switching & Prior Authorization

• SB 2389: Transmitted to the Governor

White Bagging

• SB 2378: signed by Governor

OKLAHOMA

Rebate Pass Through

• HB 2853: Referred to Senate Appropriations 

Step Therapy

• HB 1736: Reported do pass by committee

RHODE ISLAND

Accumulators

• S799: Introduced and referred to Health and Human Services committee
• H6159: Committee recommends measure be held for further study

Rebate Pass Through

• S106: Committee recommends measure be held for further study

TEXAS

Biomarker Testing

• SB 989: Approved by the Senate

White Bagging

• HB 1647: Committee substitute reported favorably  

What's Happening in the Capitol

This week, the House of Representatives reintroduced the Safe Step Act, bipartisan legislation to reform step therapy protocols in employer-based coverage. In addition to establishing other patient safeguards, the bill would codify five specific circumstances in which an exception to step therapy must be granted, including when a patient is stable on an existing medication that was previously approved by any insurer.

The bill number is H.R.2630; its Senate companion is S.652. As in the last Congress, Representative Wenstrup (R-OH-2) and Representative Ruiz (D-CA-25) led the introduction. CSRO supports this legislation, as we have in the past, and will continue to monitor and provide updates as appropriate.

Regional Town Halls: Mondays in April & May

Hear advocacy updates specific to your area and network with your community:

• April 24: IA, KS, MN, MO, NE, ND, SD, WI
• April 24: AK, CA, HI, OR, WA
• May 1: ME, MD, MA, NH, NJ, NY, PA, VA
• May 1: AL, AR, LA, MS
• May 8: IN, KY, MI, OH, TN, WV
• May 8: AZ, NV, NM, TX

Business of Rheumatology: June 14, 2023

Learn about ways to expand infusion suite services at the next installment in CSRO's virtual seminar series to help support rheumatology practices.

Virtual Advocacy Day: July 13, 2023

Advocate alongside CSRO as we host live conversations with health care leaders from the U.S. Senate and U.S. House of Representatives.

Advocacy Conference: August 25-27, 2023

Join us in Austin for our Advocacy Conference and celebration of our 20th Anniversary! 

Action Center

Use CSRO's convenient online platform to easily find out who your elected officials are and engage with them directly

Advocacy Council

Amplify your voice by assembling with other like-minded individuals to enhance CSRO’s advocacy initiatives.

Legislative Map Tool

Find your state on our interactive map tool to learn about current or proposed policy and ways you can take action to make an impact.

Payer Issues Reporting Form

Request assistance with any payer relation issues that may be impacting your patients or office.

Policy Correspondence

Easily access all of CSRO’s policy letters submitted to payers, state, and federal governments as an informational resource.

CSRO is a 501c3 nonprofit organization that has remained dedicated to ensuring access to the highest quality care since 2003 – donate today.

Questions?

Please visit the CSRO website for other news and updates, and do not hesitate to contact us with any questions at info@csro.info.