News

Proposed HHS Secretary, Robert F. Kennedy, Jr., Aims to End Chronic Disease Epidemic and Implement Additional Benefits for Medicare and Medicaid

• Should he be confirmed as Health and Human Services (HHS) Secretary, Robert F. Kennedy, Jr. has pledged to reduce rates of chronic disease, offer additional benefits to Medicare and Medicaid beneficiaries, and protect Americans from harmful chemicals, pharmaceutical products, and food additives. The organization he founded, Children’s Health Defense, estimates that by age 20, approximately 54% of children and youth in America are chronically ill with depression, obesity, suicidal thoughts, developmental disorders, anxiety, ADHD, asthma, food allergies, autism, and cancer. Some of the additional benefits Kennedy supports have previously been proposed, including Medicare and Medicaid coverage for medically tailored meals and the use of section 1115 demonstration waivers to provide nutrition education and supports. Kennedy has indicated support to further these initiatives, including the provision of gym memberships and food (Inside Health Policy, November 14).

Potential for PBM Reform in the Lame-Duck Session

• Over the last two years, Congress has struggled to pass legislation targeting pharmacy benefit managers (PBM). Now, lawmakers are back for the lame-duck session where there is a chance that PBM reforms could be passed before the 119th Congress convenes in 2025. Observers remain optimistic that bipartisan support for PBM reform will enable legislation to pass in the year-end appropriations and extensions of health-related bills. Although legislation may be stalled until the new year, PBM reform could potentially fund telehealth and home care extensions in Medicare. According to experts, potential areas of focus for PBM regulations include increasing transparency and “delinking” PBM revenue from drug rebates. However, the Pharmaceutical Care Management Association (PCMA) opposes reforms, arguing that these would weaken negotiating power against drugmakers. To avoid a government shutdown, Congress must pass federal funding by December 20 (Modern Healthcare, November 15).

Dr. Mehmet Oz Nominated as Head of CMS

• President-elect Donald Trump has nominated Dr. Mehmet Oz to head CMS. Dr. Oz is a notable TV host as well as a professor emeritus of cardiothoracic surgery at Columbia University. He previously served on the Presidential Council on Sports, Fitness and Nutrition during the president-elect’s first term in office. Dr. Oz has been highly supportive of Medicare Advantage over the years. In 2020, he co-wrote an article in Forbes making the case for “Medicare Advantage for All,” to improve chronic illness, increase the use of value-based payment models, and reduce health disparities. If confirmed as Director of CMS, other policies that Dr. Oz will likely support include permanent telehealth flexibilities; wearable health technology and remote monitoring; and artificial intelligence tools, sometimes called “augmented intelligence,” to support doctors in making medical decisions (Inside Health Policy, November 19; Inside Health Policy, November 19).

Federal Regulation and Guidance

CMS Releases SMD #24-004 On Extending Medicaid Coverage for SUD

• On November 19, the Centers for Medicare & Medicaid Services (CMS) released State Medicaid Director (SMID) Letter #24-004, providing guidance on various provisions of the Consolidated Appropriations Act of 2024 (CCA, 2024) related to Medicaid coverage of Substance Use Disorders (SUD). Section 201 made medications for opioid use disorder (MOUD) a permanent Medicaid benefit; Section 204 made permanent and amended the state plan option at section 1915(I) of the Social Security Act to allow medical assistance for certain individuals who are patients in eligible Institutions for Mental Diseases (IMDs); and Section 211 made permanent a managed care provision related to Medical Loss Ratio (MLR) remittances.
  • With changes to Section 201, states will continue to have the option to request an exemption from the MOUD benefit requirement due to a documented provider shortage, as described in SHO #20-005, which is subject to re-certification every five years. There are several changes in Section 204 of the CAA, 2024 related to MOUD coverage and access to IMDs for which CMS has provided new guidance: Maintenance of Effort (MOE) funding requirements, effective March 9, 2025; requirements for placement criteria and utilization management to ensure enrollees receive the appropriate level of care, effective October 1, 2025; establishing a new review process for eligible IMDs, effective October 1, 2025; and a new requirement for states no later than 12 months after the approval of a SPA to assess the availability of SUD treatment for beneficiaries at each level of care, including the availability of medication-assisted treatment. States that have a SPA approved as of September 30, 2023, must begin the availability assessment by March 9, 2025, and have it completed within a year. CMS also noted that Section 211 removed the limited timeframe for states to keep a larger percentage of MLR remittances collected specific to the expansion population (CMS, November 19).

DEA Announces Telemedicine Prescription Flexibility Extensions

• On November 15, the Drug Enforcement Administration (DEA) announced that it will be extending telemedicine flexibilities for controlled medications for the third time. The temporary rule will be effective from January 1, 2025, through December 31, 2025. The extension was supported by telehealth advocacy groups as it ensures uninterrupted patient care. The executive director at the Center of Telehealth and e-Health Law, noted the possible factors that could impact actions to make these flexibilities permanent during the one-year extension period, including the the time it takes to staff federal agencies such as DEA and HHS under the new Trump Administration . It is also possible that the new Administration could opt to accelerate a permanent extension of telehealth flexibilities (Inside Health Policy, November 15; Federal Register, November 19).