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Consultant Corner: Inflation Reduction Act Implementation Best Practices and Planning for the Future

By December 12, 2022Consultant Corner, IRA
jeff baker
Jeff Baker, is a BluePeak Senior Health Plan Services Consultant.

On August 16th, the Inflation Reduction Act of 2022 (IRA) was signed into law.  The text of the bill is located here and includes changes that directly impact plans and enrollees as early as 2023.  While details are still being released, plans have most of the operational guidance needed to implement the 2023 IRA changes.  BluePeak has documented some industry best practices to ensure a smooth and compliant implementation of the Insulin and Advisory Committee on Immunization Practices (ACIP) vaccines provisions that apply in 2023.

  • Insulins:  Enrollee cost sharing cannot exceed more than $35 for a one-month supply
    1. Year-end testing
      1. Year-end testing will be critical to validate Part D insulin products are paying and reporting appropriately. Testing should include a combination of scenarios including products being processed inside and outside of transition, variety of day supplies, variety of pharmacy types (Including out of network (OON)), and for low-income and non-low-income enrollees.  Claims should also be evaluated within and straddling between all benefit phases, including the deductible, to ensure cost sharing and the Inflation Reduction Act Subsidy Amount (IRASA) is being calculated and applied correctly.  Lastly, a test Prescription Drug Event (PDE) file should be created to ensure the PDE changes have been successfully adopted.
    2. Post go-live
      1. Following implementation, daily claims monitoring and oversight should target insulin products and ensure any enrollee cost sharing is within the IRA maximums for a one-month or extended day supply. Non-compliant situations should be urgently researched and remediated.  Impacted enrollees should be refunded within 30 days.  To provide another layer of review, Insulin products should be reviewed on the first PDE file created for PDE files should be reviewed.  If compliance has been demonstrated, plans can adjust the monitoring cadence.
  • Vaccines:  No enrollee cost sharing applied on ACIP vaccines.
    1. Year-end testing
      1. Year-end testing will also be critical to validate there is no enrollee cost-sharing on ACIP vaccines. Plans should coordinate with their PBM to finalize the drug list of ACIP vaccines.  Testing should include a combination of scenarios including ACIP vaccines being processed inside and outside of transition, variety of day supplies, variety of pharmacy types (Including out of network (OON)), and low-income and non-low-income enrollees.  Claims should also be evaluated within and between all benefit phases, including the deductible, to ensure cost sharing and the Inflation Reduction Act Subsidy Amount (IRASA) is being calculated and applied correctly.  Lastly, a test PDE file should be created to ensure the PDE changes have been successfully adopted.
    2. Post go-live
      1. Following implementation, daily claims monitoring and oversight should target ACIP vaccine products and ensure no cost sharing is being applied. Non-compliant situations should be urgently researched and remediated.  Impacted enrollees should be refunded within 30 days.  PDE files should be reviewed to provide another layer of monitoring as the Centers for Medicare and Medicaid Services (CMS) will reject any ACIP vaccines with an enrollee cost-sharing.  If compliance has been demonstrated, plans can adjust their monitoring cadence.

Next year will be a busy year with the new IRA provisions.  With additional provisions scheduled to be implemented in the years following 2023, it is essential to setup a solid infrastructure of testing and monitoring to avoid situations of non-compliance that ultimately impacts the enrollee’s experience with the health plan.  BluePeak continues to support plans and Pharmacy Benefit Managers (PBMs) with performing testing and ongoing monitoring and oversight of these areas.  Please contact us for any assistance or support needed to successfully implement these provisions.

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