PROVIDER ALERT: CMS Issues Guidance to Ensure Patient Access Amid COVID-19

The Center for Medicare & Medicaid Services (CMS) released a moratorium on March 10, 2020 directing Medicare Advantage Organizations (MAOs), Medicare Part D Sponsors (Sponsors), Medicare-Medicaid Plans (Plans), and consequently, pharmacy providers to remove certain barriers that could hinder patients from receiving healthcare services in the wake of the coronavirus (COVID-19) outbreak. CMS further provided that the waivers will help enable beneficiaries to have access to healthcare services and allow Plans to work with pharmacies and providers to treat patients without burdensome requirements limiting their options during this outbreak.

More specifically, the moratorium outlined the flexibilities that will permit MAOs, Sponsors, and Plans to waive certain requirements to help prevent the spread of COVID-19:

  • Waiving cost-sharing for COVID-19 tests
  • Waiving cost-sharing for COVID-19 treatments in doctor’s offices or emergency rooms and services delivered via telehealth
  • Removing prior authorizations requirements
  • Waiving prescription refill limits (i.e., refill too soon)
  • Relaxing restrictions on home or mail delivery of prescription drugs
  • Expanding access to certain telehealth services

CMS further noted that Sponsors are required to reimburse enrollees for prescriptions obtained from out-of-network pharmacies if enrollees cannot reasonably be expected to obtain covered drugs at a network pharmacy.

While this guidance leaves a great deal of discretion to MAOs, Plans and Sponsors, we feel there is nonetheless great opportunity for pharmacies to demonstrate the need for removing certain barriers to better serve their patients. For example, this moratorium may be helpful, particularly for specialty pharmacies, in being able to provide prescriptions through the mail or service patients despite not being contracted in a particular payor network. Additionally, it is even possible that pharmacies that have been terminated from Part D networks could nevertheless be able to service Part D beneficiaries and to seek payment for out-of-network claims.

For more information, or to explore how this recent guidance may provide opportunities for your pharmacy, contact Frier Levitt to speak with an attorney.

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