Medicare Physician Fee Schedule

Congress recently enacted another short-term extension of government funding to avert a shutdown. The new extension runs through March 1 for some agencies and March 8 for others. This extension did not contain any provision to address the 3.37% cut across-the-board to the Medicare Physician Fee Schedule that went into effect on January 1, 2024. Mitigating the impact of the cut for the remainder of 2024 remains under discussion for inclusion in a package of health policies for March, but by then the impact of the reduction will have been fully felt on physician reimbursement.

CSRO thanks the rheumatology community for its strong response to our advocacy efforts, and while the news on the broader PFS update is grim, there is another CMS policy that buffers the negative impact on rheumatology – the implementation of active payment status for the complex care add-on code, G2211. This policy provides a slight boost in payment for rheumatologists who employ the code in practice.

Recently, CMS posted a new MLN Matters article on the new add-on code, which largely follows the preamble of the CY 2024 Medicare PFS final rule. The article provides examples of when and how to use and document the service. As additional details emerge, we will keep you updated.

CMS Prior Authorization Rule Released

Last week, CMS released its Interoperability and Prior Authorization Final Rule that requires “impacted plans” – including MA, QHP, MCOs, CHIP & ERISA - to streamline prior authorization processes.

Under the new requirements, most plans must answer prior authorization requests for “items and services” within 72 hours or seven calendar days, depending on the urgency of the request, and provide a specific reason when a request is denied. Plans will also be required to publicly report on key prior authorization metrics, similar to these metrics. In addition, CMS finalized a new MIPS measure on e-prior authorizations for reporting by eligible clinicians.

More details on these and other provisions, including timeframes for compliance, can be found in a CMS Fact Sheet.

Administration Changes Course on Appeal of Copay Accumulator Ruling

Last year, CSRO joined an amicus brief in federal litigation brought by the HIV + Hepatitis Policy Institute against the Department of Health and Human Services, challenging the regulation that allowed for use of copay accumulators in the Affordable Care Act exchanges.

In its ruling, the court sided with the patient and provider groups and struck down the regulation, which was a major victory. Initially, the Administration filed a notice of its intent to appeal, but many of the same patient and provider groups – as well as a group of bipartisan lawmakers – urged the Administration not to appeal this ruling. The Administration clearly listened to all of this feedback because, on January 16, it announced that it is no longer planning to appeal.

Although this is welcome news, a future Administration could decide to go in a different policy direction with copay accumulators. That’s why CSRO will continue to work to enact the HELP Copays Act, which would codify into federal law a prohibition on use of these insurer programs.

CSRO recently learned that Florida Blue MA plans terminated approximately 2/3 of rheumatologists from their provider networks, creating access to care challenges for a significant number of beneficiaries in the state. CSRO has secured a meeting with federal regulators next month to discuss these provider terminations and is now calling on the rheumatology community to gather information.

Have you or other rheumatologists in your state experienced similar terminations? If so, please email info@csro.info with any details you can provide, including termination letters your practice received, and any letters your patients may have shared with you that notifies them of their provider’s termination from the network. 

CSRO has heard increasing reports about insurers – namely in the Exchanges and Medicare Advantage plans – using “narrow networks” to control their costs, with some touting this as a way to keep premiums low for their insureds. Any input provided will help us better understand the full scope of the issue.

Thank you to everyone who tuned in on Monday night for CSRO's National Town Hall to hear updates on our federal legislative and regulatory advocacy work and insights into new trends and anticipated legislation in the states.

A recording of the town hall and the presentation slides are available in CSRO's Education Library.

Weren't able to attend? Share your input via this brief three-question survey! Your feedback is crucial in shaping CSRO's policy priorities for the year ahead, and we appreciate you sharing your perspective on the issues impacting rheumatology.

"As the saying goes, 'The more things change, the more they stay the same.' That is particularly true when it comes to the affordability of drugs for our patients even after the launch of so many Humira biosimilars. And we still have the “musical chairs” game of formulary construction — when the music stops, who knows whether your patient’s drug found a chair to sit on."

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

Fellows Conference

March 1-3, 2024

Registration closes

January 29 at noon CT.

Ensure the fellows in your network are in attendance at CSRO's Fellows Conference this March in Austin, Texas – a free and unique event designed by rheumatologists specifically for rheumatology fellows.

The program will center around topics and skills not taught in medical training and was curated to help guide fellows in their transition to practicing rheumatologists. View the full agenda on our website.

There are only three days left to secure a spot; share the event with any fellows you know today!

CSRO is recruiting for a Fellow-at-Large to serve as a non-voting member of our Board of Directors for a one-year term beginning May 1.

This position provides a unique experience for a rheumatology fellow to engage with CSRO's Board members, who are rheumatologists from across the United States with years of varied career experiences, and to be a liaison to other fellows as they learn more about the importance of advocacy in rheumatology. 

The application deadline is March 28. Interested or know someone who might be? Check out our website to learn more and apply.

CSRO Fellows Conference: March 1-3, 2024

An annual event to help rheumatology fellows prepare for their future roles as practicing rheumatologists. Registration closes Monday, January 29, at noon CT.

CSRO Advocacy Conference: September 20-22, 2024

Mark your calendars to join us in Nashville for CSRO's annual Advocacy Conference! 

State Society Conferences:

CSRO's state rheumatology society members host their own annual meetings throughout the year – find a listing of these state conferences on our website.

What's Happening in the States

CSRO tracks legislative activity relevant to the rheumatology community and their patients. A full status report of CSRO priority bills is included below, and a printable version is available here.

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

Alaska

White Bagging

• HB 226: Referred to Health and Social Services committee

Arizona

Non-medical Switching

• SB 1164: Introduced and referred to committees

Colorado

White Bagging

• HB 1010: Assigned to Health and Human Services committee

Florida

Accumulators

• SB 228: Referred to Banking and Insurance, Health Policy, and Appropriations committees 
• HB 363: Referred to Committee on Health Innovation

Non-medical Switching

• SB 924: Introduced
• HB 1543: In select Committee on Health Innovation

Biomarker Testing

• SB 964: Introduced
• HB 885: Now in Appropriations committee
• HB 885: Now in appropriations committee  

Georgia

White Bagging

• HB 924: Introduced

Hawaii

Biomarker Testing

• HB 2223: Introduced
• SB 2551: Introduced

Illinois

Prescription Drug Affordability Board

• HB 4472: Referred to the Rules committee

Indiana

Biomarker Testing

• SB 273: Reported do pass, reassigned to appropriations committee
• HF 2157: Introduced

Prior Authorization - Gold Card:

• SB 3: Referred to Committee on Health and Provider Services
• HB 1091: Introduced and referred to Committee on Insurance

Iowa

Biomarker Testing

• SSB 3001: Subcommittee recommends amendment and passage
• HB 2157: Introduced

Kentucky

Prior Authorization - Gold Card

• HB 318: Referred to Committee on Committees

White Bagging

• HB 190: Referred to Committee on Committees

Maine

Biomarker Testing

• LD1577: Introduced

Rebate Pass Through

• LD 1165 & HP 737: Carried over in the same posture to the new legislative session

Maryland

Prescription Drug Affordability Board

• SB 388: Hearing scheduled for 2/07
• HB 340: Referred to Health and Government Operations

Michigan

Accumulator

• HB 4719: Referred to committee on Insurance and Financial Services

Prescription Drug Affordability Board

• SB 483: Referred to House committee on Insurance and Financial Services 

Rebate Pass Through

• H5338: Referred to committee on Financial Services 

Step Therapy

• H5339: Referred to committee on Insurance and Financial Services

Mississippi

Non-medical Switching

• HB 339: Referred to Insurance committee

White Bagging

• HB 320: Referred to Public Health and Human Services

Missouri

Accumulators

• HB 1628: Introduced
• SB 844: Introduced
• SB 1106: Introduced
• SB 1190: Introduced

Gold Card

• HB 1976: Reported do pass by committee

White Bagging

• HB 2267: Introduced 

New Jersey

Accumulators

• S1047: Referred to Commerce Committee

Prescription Drug Affordability Board

• A1646: Referred to Assembly Financial Institutions and Insurance committee

New Mexico

Step Therapy

• SB 135: Referred to Committees’ committee
• HB 185: Referred to House Health, and House Judiciary committees

New York

Biomarker Testing

• S1196: Signed into law

Step Therapy

• A1384: Referred to Insurance
• S1267: Approved by committee
• A901: Referred to Insurance
• A582: Referred to Insurance
• A463: Signed into Law
• S2682: Referred to Insurance
• S2800: Referred to Insurance
• S3400: Referred to Health
• S3402: Referred to Health

PBM and Rebate Aggregator Transparency

• S6738: Approved by committee 
• A7304: Referred to Codes committee

Rebate Pass Through

• S2393: Referred to Insurance
• A1962: Referred to Insurance
• White Bagging
• A2163: Referred to Insurance
• S7413: Referred to Insurance

Nebraska

Gold Card

• LB 210: Carried over into 2024

Prescription Drug Affordability Board

• LB 833: Notice of hearing for 2/27

White Bagging

• LB 448: Carried over into 2024

New Hampshire

Accumulators

• SB 354: Hearing held 1/24

White Bagging

• HB 513: Referred for interim study 1/3

Rhode Island

White Bagging

• S2086: Referred to Health and Human Services committee

Utilization Management Reform & PBM Regulation

• H7139: Referred to House Corporation committee

South Carolina

Accumulators

• HB 3618: In Labor, Commerce, and Industry committee

Utah

Accumulators

• SB 152: Introduced

Vermont

Biomarker Testing

• H532: Referred to committee on Health Care

Utilization Management Reform

• H766: Referred to Committee on Health Care

Virginia

Prescription Drug Affordability Board

• SB 274: Referred to Commerce and Labor committee
• HB 570: Assigned to Health subcommittee  

Rebate Pass Through

• HB 1041: Assigned to subcommittee

Washington

Biomarker Testing

• SB5074: Reintroduced
• HB 1450: Reintroduced

Rebate Pass Through

• SB 5445: Reintroduced
• HB 1465: Reintroduced

West Virginia

Biomarker Testing

• HB 4753: Reported do pass with amendments, re-referred to Judiciary

White Bagging

• HB 4174: Referred to Health and Human Resources committee

Wisconsin

Accumulators, Non-medical Switching, & PBMs

• SB 737: Introduced and Senate hearing held
• AB 773: Referred to committee on Health, Aging and Long-term Care

Wyoming

Gold Card

• HB 14: Introduced and bill number assigned

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.

Career Center

Locate the perfect fit whether you're looking for new career opportunities or trying to find the right candidate.

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.

Rheum for Action

Learn about the latest advocacy issues in CSRO's advocacy column produced in partnership with Rheumatology News.

Step Therapy Cover Sheets

Review CSRO's state-specific step therapy materials that help guide practices in gaining an exemption from step therapy protocols.

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.