The FEHBlog cringes whenever he sees an email announcing a new set of Affordable Care Act FAQs. He cringed yesterday when FAQ XXVII was issued. Part one of the FAQs was an effort by the regulators to circle the wagons around HHS. A few months ago, HHS released the 2016 notice of benefit and payment parameters, a massive annual rule making. HHS explained in the preamble that health plans, beginning in 2016, must embed a self only out of pocket maximum in other than self and family coverage. Confusion reigned because HHS overlooked actually adding this requirement to the rules. Rather than amend the rule-making, HHS issued sub-regulatory guidance to cover its tail which climaxed in FAQ XXVII. The ACA regulators collectively assert in FAQ XXVII that the embedded OOP maximum rule applies to all non-grandfathered plans, including group plans (e.g., FEHBP) and high deductible health plans. Cost curve up.
The other part of FAQ XXVII continues the saga of ACA FAQ XV which addressed in part the ACA’s provider non-discrimination rule, PHSA § 2706. In response to Congressional complaints, no doubt spurred on by the chiropractor and other allied health professional lobbyists, the ACA regulators retracted the meat of the guidance of FAQ XV which of course favored health plans. The other shoe should drop before long with a new rule. Cost curve up again.
The reason that the FEHBlog cringes upon the release of ACA FAQs is that the FAQs typically announce consumer protections that push the cost curve up just as we creep ever closer to 2018 when the high cost coverage excise tax kicks in as discussed in a recent post. It’s unfortuante that the ACA regulators can’t simply let health plans offer consumers choice. In the FEHBP some plans offer embedded self only OOP maximums in self and family coverage. Others don’t. If a consumer wants the embedded maximum, he or she can find it (via the summary of benefits and coverage or the plan brochure).
The Wall Street Journal reports that
[As] part of a growing push for so-called pay-for-performance deals amid complaints about the rising price of medications, some of which cost more than $100,000 per patient a year [, s]ome insurers and prescription-benefit managers are * * * arguing that they should pay less when drugs don’t work well in certain patients. Drug companies are countering with pricing models of their own, such as offering free doses during a trial period.
The FEHBlog does not quite follow this approach. If a much lower price is charged when the drug is ineffective, won’t that encourage use of the drug on those cases? In any event, Drug Channels reports on the drug trend reports of Express Scripts, CVS Health, Catamaran, and Prime Therapeutics. .