Insurance Advocacy Current Issues

Insurance advocacy


The ACR Insurance Subcommittee and staff are dedicated to working on regional and national insurance issues to secure patient access and fair and consistent reimbursement for providers. Below is information on some of the issues we are currently working on.

Medicare Contractors Delay Addition of Stelara to SAD List

In March, most of the Medicare Administrative Contractors (MACs) announced plans to move Stelara to the Self-Administered Drug (SAD) with effective dates ranging from April 20-May 3, 2020. Moving this drug to the SAD list would prohibit patient access under Medicare Part B.

The ACR opposes moving Stelara to the SAD list, particularly during the current health crisis we’re facing as a result of the COVID-19 global pandemic. ACR reached out to each of the MACs individually and also led a multispecialty sign-on letter to CMS urging them to weigh in and advise the MACs to delay this change.

The MACs have subsequently decided to delay the addition of Stelara to the SAD list until 45 days after the end of the public health emergency. The ACR remains concerned about the appropriateness of moving this drug to the SAD list and the impact of this decision on patient access. Doing so would leave vulnerable patients with limited treatment options. ACR advocacy efforts will continue to prioritize protecting Part B access to this drug.

Multispecialty Sign-On Letter to CMS - Addition of Stelara to SAD List
Rheumatology Sign-On Letter to CMS - Addition of Stelara to SAD List

Mandated Specialty Pharmacy Acquisition of Physician-Administered Treatments

Several commercial insurance companies and pharmacy benefit managers (PBMs) have implemented policies mandating that in-office treatments be purchased through specialty pharmacies instead of the traditional “buy-and-bill” system. In some cases, employers are being given the choice to include these requirements as part of their employee health plan without fully understanding the impact on patient care and access to treatment.

Blue Cross Blue Shield of Tennessee (BCBST) announced last fall that all specialty drugs would have to be acquired through the BCBST specialty pharmacy network as of January 1, 2020. After significant opposition from stakeholders, including the ACR, BCBST pushed back the implementation date of the policy to July 1, 2020. ACR has subsequently requested further delay during the current COVID-19 public health crisis; however, the payer remains committed to moving forward with the planned implementation date.

The ACR is very concerned about the impact of these policies on patients’ access to critical in-office treatments. We are providing education to patients and employers regarding the potential harm of these policies and will continue to advocate against the policies proposed by BCBST and other payers. In light of the unprecedented challenges faced as a result of COVID-19, ACR will also continue to urge payers to delay any policy that would increase administrative burden or disrupt patient care so that members can remain focused on patient care at this critical time.

Fact Sheet: Protect Access to Physician-Administered Therapies - March 2020
Template Employer Letter from Practices – Physician-Administered Therapies
Specialty Pharmacy Mandates - Media Resources for Practices
Rheumatology Letter to BCBS TN - December 2019
Multi-Specialty Letter to BCBS TN - February 2020

Commercial Payers Discontinuing Payment for Consultation Services

As of October 19, 2019, payers will implement a new policy on Evaluation and Management (R30) which will deny claims billed with CPT codes for consultation services as not valid. Impacted CPT codes include 99241, 99242, 99243, 99244,99245, 99251, 99252, 99253, 99254, and 99255.

Cigna is the second major payer to discontinue payment for consultation services in 2019. UnitedHealthcare announced earlier this year that they would also eliminate the consultation codes in two phases. On June 1, 2019, UHC discontinued payment for practices whose contracted rates are based on a stated year 2010 or later Medicare fee schedule. As of October 1, 2019, they completely eliminated reimbursement for consultation codes for all practices. Medicare previously discontinued payment for consultation services in 2010.

The ACR is very concerned about the impact of these changes on rheumatology practices. The undervaluation of cognitive care is a serious issue. CMS recently acknowledged this by proposing an increase in reimbursement for many evaluation and management (E/M) services in the CY 2020 Revisions to Payment Policies Under the Physician Fee Schedule proposed rule. Given that the current healthcare environment is moving towards a more appropriate valuation of cognitive care, it is most alarming that commercial payers would move to stop recognizing consultation services at this time.

The ACR will continue to oppose any payer efforts to eliminate reimbursement for consultation services while advocating for appropriate recognition and compensation of rheumatologists’ expertise and training.

Cognitive Specialty Coalition Letter to Cigna - Elimination of Consultation Codes
ACR Letter to Cigna - Elimination of Consultation Codes
ACR Letter to UnitedHealthcare - Elimination of Consultation Codes

UnitedHealthcare Coverage for Physician-Administered Treatments

On October 1, 2019 UnitedHealthcare (UHC) announced updates to their policies for Actemra, Benlysta, Cimzia, Orencia, Simponi Aria, and Stelara. The policy changes were effective immediately and required all patients to fail the self-administered formulation of these drugs prior to obtaining authorization for the physician-administered product. An exception would be granted only if the physician could attest that both patient and caregiver were unable to self-administer.

UHC has since delayed the policy changes for Actemra, Benlysta, Cimzia, Orencia, and Simponi Aria. Practices should instead refer to the policies that were in effect prior to October 1 for these drugs. The changes to the Stelara policy remain in effect and have not been delayed. If a valid prior authorization is in place for in-office administered Stelara, it will be honored until its expiration; however, the ACR encourages members to watch these charges closely. UHC has indicated that the delayed policies are still under consideration though no future effective date has been set.

The ACR opposes these changes and is actively working with other rheumatology groups to advocate for the permanent rescission of the policies.

Rheumatology Letter to UnitedHealthcare on Coverage for Physician-Administered Treatments

Site of Service Restrictions for Infused Biologics

Since 2015, the ACR has engaged with ten different health plans regarding policies that limit the site of service for patients receiving infusions. The payers implementing these policies have the stated goal of moving infusions from hospital outpatient facilities to other, less costly settings. The policies permit patients to receive their infusions at home, in a physician’s office, or in another non-hospital based infusion center. Most grant exceptions for initiating or reinitiating therapy as well as patients with a history of severe infusion reactions or other medical risks or comorbidities. The ACR continues to dialogue with these health plans as we advocate for patient access in a monitored health care setting with on-site supervision by a provider with appropriate training.

ACR Position Statement on Patient Safety and Site of Service for Infusible Biologics

Co-Pay Accumulator Programs

The ACR has begun to see several health plans implementing copay accumulator programs to counter the use of manufacturers’ copay assistance programs and shift costs to the patient. These programs prohibit the application of copay assistance funds toward the patients’ deductible or out-of-pocket maximum. When the funds from the assistance program run out—typically in the middle of the plan year—the patient must go out of pocket until they reach their deductible or out-of-pocket maximum. ACR/ARP members report that patients are caught off guard by the resulting increase in out-of-pocket costs, and some may feel forced to discontinue treatment due to cost. Per the ACR’s position statement, Programs Limiting Copay Assistance, the ACR opposes insurance restrictions that prevent application of funds from assistance programs toward patients’ deductibles and out-of-pocket maximum payments.

Coverage for Remicade and Infliximab Biosimlars

Health plans across the country have begun enacting policies on the coverage status of Remicade (infliximab) and the biosimilars, Inflectra (infliximab-dyyb) and Renflexis (infliximab-abda). Many plans are designating either the originator or biosimilar as their preferred products and limiting coverage for patients who are new to therapy.. Several plans have also attempted to force-switch patients who are currently stable on therapy. Members should refer to each plan’s coverage policy for additional information including exceptions criteria. The ACR is actively reviewing this issue and will continue to advocate for coverage policies that allow providers to choose the most clinically appropriate treatment for each patient.

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