Word from Washington: October 2023

Hemophilia Federation of America and allied patient advocates cheered a Sept. 29 court decision setting aside a federal rule that harms people who rely on copay assistance. The rule at issue permitted health plans to implement so-called “copay accumulator adjuster programs” (CAAPs)—strategies whereby health plans accept copay assistance, but refuse to credit those amounts toward patient deductibles and out-of-pocket maximums.  

The court ruling comes in a lawsuit filed by the HIV and Hepatitis Policy Institute and two diabetes groups against the U.S. Department of Health and Human Services. Plaintiffs challenged HHS’s 2021 rule that allowed health plans to implement CAAPs. The 2021 rule, plaintiffs alleged, was internally inconsistent and conflicted with existing federal statutes and regulations. HFA and other patient advocates, led by the Aimed Alliance, filed an amicus curiae brief supporting the plaintiffs’ position.   

In the Sept. 29 ruling, the court accepted plaintiffs’ argument that HHS’s regulation relied on two contradictory and unsupported interpretations of the term “cost-sharing,” but declined to choose which interpretation should prevail. Instead, the court vacated the 2021 rule and directed HHS to reconsider its interpretation of the relevant language.  

While the court’s ruling is a preliminary victory for consumers and patients, the full impact of the decision may not be known until HHS completes its review and revisions of the 2021 rule. Patient groups have urged HHS and the U.S. Department of Labor (a) not to appeal the ruling, (b) to issue guidance stating that the agencies will enforce regulations from 2019 (i.e., pre-dating the challenged rule) which required health plans to count copay assistance toward patient cost-sharing in most circumstances; and (c) to require health plans to inform enrollees of the change in policy regarding CAAPs.  

Meanwhile, HFA and allied patient advocates remain committed to securing passage of federal and state legislative protections for individuals who rely on copay assistance to afford their medications. The federal HELP Copays Act (H.R. 830/S. 1375) would codify patient protections against CAAPs and, critically, would rein in copay maximizers (not impacted by the court ruling). Support for the HELP Copays Act will be a principal ask during HFA’s upcoming fly-in. Please stay tuned for how you can make your voice heard on this important issue! 

Quick Hits: 

• Congressional movement hit a significant slow-down during October, due to a vacancy in the House Speakership following the nearly unprecedented ouster of Kevin McCarthy. After three weeks of uncertainty, Congressman Mike Johnson (R-LA 4^th district) won election to the Speakership. Congress must now pass funding (full-year or stopgap) by November 17 in order to avert a government shutdown.  
• Open enrollment season is beginning for 2024 health insurance coverage.  
  • Medicare Open Enrollment began Oct. 15 and runs through Dec. 7. This is the time of year when enrollees can most easily change their Medicare Advantage or Part D drug plan, or switch between Original Medicare and Medicare Advantage. Read more in October’s Dear Addy post. 
  • Open enrollment for 2024 coverage through the ACA Marketplaces will run from (at least) Nov. 1 through Dec. 15. 
  • Open enrollment for employer-sponsored insurance often (but not always) takes place in the Fall. Check with your employer’s human resources department to find out when your plan’s open enrollment period begins and ends. 
  • Enrollment in Medicaid is available 365 days per year, based on need, income, and other state-specific eligibility criteria. 

• On Oct. 12, 2023, the U.S. Centers for Medicare & Medicaid Services (CMS) published the 2024 premiums and cost-sharing amounts for the Medicare Part A and Part B programs. The standard monthly premium for Medicare Part B enrollees will be $174.70 for 2024, an increase of about $10/month from 2023. The annual deductible for all Medicare Part B beneficiaries will be $240 in 2024, an increase of $14 from the annual deductible of $226 in 2023. 
• Social Security and Supplemental Security Income (SSI) benefits for more than 71 million Americans will increase 3.2 percent in 2024. SSA anticipates that, on average, beneficiaries will see an increase of more than $50 per month. 
• North Carolina received federal approval to start its Medicaid expansion program on December 1, 2023, following resolution of a five-month budget standoff in the state legislature. 
• The U.S. Drug Enforcement Administration announced that it would continue COVID-era rules allowing for telehealth prescribing of controlled substances, through the end of 2024. The agency explained that the rule extension is intended to ensure a smooth transition for patients and providers, and allow time for providers to come into compliance with any new standards or safeguards.