On Friday, CDC announced recommendations for boosters of the Pfizer COVID-19 vaccine for people who: are 65 and older, live in long-term care settings, are at high risk for severe illness, or work in a high-risk job. Today’s Policy Roundup includes those details, along with the following:
- CMS guidance: ARP Act funding for Medicaid and CHIP (Coverage of habilitation services, COVID-19 testing and vaccination, and more).
- Input needed: Medicare drug pricing rule
- Input Needed: NQF Rural Telehealth and Healthcare System Readiness Measurement Framework
- Medicare.gov Tool to Compare Nursing Home Vaccination Rates
CDC recommendations for COVID-19 vaccine boosters
On Friday, the CDC recommended booster shots of the Pfizer COVID-19 vaccine for people at highest risk of serious illness and those in high risk occupational and institutional settings. Specifically, CDC guidance now states that people who received their second shot at least six months ago:
Should receive a booster shot if they are:
- 65 years old or older
- 18 years old or older and live in a long-term care setting
- aged 50–64 years and have underlying medical conditions
May receive a booster shot, based on their individual benefits and risks, if they are:
- 18–49 years old and have underlying medical conditions
- 18–64 years year old, and at increased risk for COVID-19 exposure and transmission because of occupational or institutional setting. The CDC website includes a complete list, but it includes front line healthcare workers and congregate care staff.
CDC will evaluate available data in the coming weeks to swiftly make additional recommendations for other populations, as well as for people who received the Moderna or Johnson & Johnson vaccines.
CMS Guidance on Medicaid and CHIP: COVID-19 testing, habilitation services, FMAP increase
In two letters to state health officials, CMS recently provided guidance on Medicaid and CHIP requirements and flexibilities established by the American Rescue Plan Act (ARP). These include coverage of habilitation services for students with disabilities, COVID-19 testing and vaccination, and more. Some highlights:
- Remote learning has made it challenging for children with disabilities who receive Medicaid-covered services at school to get the services they need. As of August 30, states now can cover habilitation services for students who are enrolled in a section 1915(c) waiver and/or 1915(i) program who are also learning remotely all or part of the time, if schools are unable to provide those services.
- COVID-19 testing must be covered for Medicaid and CHIP beneficiaries, without any cost sharing. This applies both to tests used to diagnose COVID-19 and tests to screen someone for COVID-19 so they can return to school or work or meet requirements for travel. All types of tests approved by FDA are covered under this requirement, including at-home tests, whether those tests are sent to a laboratory to get results or not.
- The ARP included a temporary increase in the federal funding provided to states for a number of different services for Medicaid and CHIP participants.
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- The cost of administering COVID-19 vaccines is fully covered for Medicaid and CHIP beneficiaries. States also can increase provider payment rates if that increase is intended to improve access to COVID-19 vaccine administration or if the state determines that COVID-19 vaccination payment rates are too low to compensate providers based on changes in care or delivery.
- In addition, states may consider using Medicaid funding for:
- Monetary incentives to beneficiaries to receive COVID-19 and flu vaccinations
- Incentives to providers to reach set COVID-19 vaccination targets
- Paid time off to direct service professionals (DSPs)
- Expanding "no wrong door" options for enrollees. For example, through one phone call, a beneficiary can make their vaccine appointment and arrange non-emergency medical transportation to the appointment
- Direct community outreach and engagement to enrollees about vaccinesDeveloping and distributing literature and materials to inform beneficiaries about the benefits and availability of COVID-19 vaccinations
- Coordinating provider trainings on the benefits of COVID-19 vaccination and how to assist beneficiaries in accessing vaccinations
- Incentive for Expanding Medicaid: States can receive a temporary increase in federal funding if they newly elect to expand Medicaid coverage to certain low-income adults. Specifically, they can receive a five-percentage-point increase in federal matching funds for certain Medicaid expenditures for a maximum of two years. Additionally, these states will qualify for the 90% federal matching funds already available through the Affordable Care Act (ACA) for medical services for newly eligible Medicaid-expansion enrollees. This will be provided on top of other available funding increases, including the 6.2 percentage point increase in Medicaid funding provided by the Families First Coronavirus Response Act and the 10 percentage point increase in funding for home and community based services (HCBS).Medical assistance expenditures for Medicaid services provided by an Urban Indian Organization, a Native Hawaiian Health Center, or a Native Hawaiian health care system which meets certain criteria are fully covered from April 1, 2021 to March 31, 2023.
Input Needed: “Most Favored Nation” Medicare Drug Pricing Rule
Bottom line: The Centers for Medicare and Medicaid Services is seeking comment on its proposal to rescind the rule published in November 2020 to establish a Most Favored Nation (MFN) Model for setting Medicare payment rates for some Part B drugs.
The MFN model proposed to lower Medicare spending on Part B drugs by basing Medicare payments on prices paid by other countries, several of which use Quality-Adjusted Life Years (QALYs) to determine whether to cover medical treatments (include medicines). Aspects of the rule itself and the rulemaking process were challenged in lawsuits, which has prevented the rule from being implemented.
The proposed rule to rescind the MFN -- currently open for comment --would permanently prevent the policy from taking effect. Because of the significant impact of this rule on older adults and people with disabilities, we strongly encourage the aging and disability networks to provide comments and encourage the people you serve to do the same. Comments are due Oct. 12, 2021.
Advocates for older adults and people with disabilities strongly objected to the rule for several reasons.
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- QALYs: Some of the countries the MFN model would have used to set Medicare drug prices use “Quality-Adjusted Life Years” (QALYs) to make pricing and coverage decisions for medications (and other medical interventions). A QALY is equal to one year of life, in perfect health. Treatments, including drugs, are evaluated in terms of how many QALYs they offer. QALYs place a lower value on treatments that do not offer a full year of life, or that deliver less-than-perfect health – such as treatments which extend the lives of people with chronic illnesses and disabilities. (This report from the National Council on Disability explains more.)
- Discouraging use of Medicare prescription drug benefits: In addition to concerns regarding payment methodology, the rule came under fire because the savings it would generate was expected to largely come from “beneficiaries not accessing their drugs through the Medicare benefit.” If Medicare reimbursement for drugs is lowered below the actual purchase prices of the drugs, medical practices would have to pay the difference in order to offer the drugs to their patients. If they do not offer the drugs, their patients would have to travel to a healthcare facility that is not part of the MFN Model (which would be difficult); find a hospital providing the drugs through discount programs (burdensome and dangerous during COVID-19); or choosing to “forgo access.” Much of the savings from the MFN Model are expected to come from Medicare beneficiaries forgoing access.
- No comment period: Finally, the rule was established without the opportunity for public comment that typically is included in federal rulemaking.
Input Needed: NQF Rural Telehealth and Healthcare System Readiness Measurement Framework
Bottom Line: The National Quality Forum (NQF) is seeking input on the Rural Telehealth and Healthcare System Readiness Measurement Framework. Comments may be submitted through the project page through Friday, October 8 at 6:00 PM ET.
Why this is important: Rural communities commonly face shortages in healthcare professionals, lack of transportation options and other challenges to accessing health care, and these issues have been exacerbated by the COVID-19 pandemic. Telehealth has the potential to increase access to care and improve quality of care in rural communities, particularly during emergencies.
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This framework covers quality of care delivered by telehealth, health system readiness, and health outcomes in a disaster, and includes five domains:
- Access to care and technology;
- Costs
- Business models, and logistics;
- Experience;
- Effectiveness; and
- Equity
This work builds on NQF’s 2016 Telehealth Framework to Support Measure Development and 2019 Healthcare System Readiness Measurement Framework. The report also includes a list of 26 measures and 43 measure concepts that may be relevant for use with the new measurement framework.
Medicare.gov adds vaccination rates to nursing home details
Last week, CMS launched a new feature on Medicare.gov to make it easier to check COVID-19 vaccination rates for nursing home staff and residents. When users search for information about nursing homes using Medicare.gov’s “Find and Compare” tool, they will now find the percentage of residents and staff who are vaccinated for COVID-19, along with the state and national rates for each.