Time to Expand Medicare Part D LTC Guidance

The Part D LTC Guidance

2021 marks the 15th year of the Medicare Prescription Drug Benefit. Many of you may recall the months leading up to implementation of the benefit in 2006. We were meeting regularly with CMS to determine how to best accommodate the needs of Medicare beneficiaries in nursing homes and other institutional settings.

One of the more significant outcomes of this exercise was the creation of the Long Term Care Guidance, which laid out pharmacy service standards for Medicare Part D enrollees residing in institutional LTC facilities. The document has been critical in establishing the services included in Medicare Part D dispensing fees.

Assisted Living Not Included

The Drug Benefit Final Rule included a definition of long-term care that was limited to any medical institution or nursing facility for which payment is made for institutionalized individuals under Medicaid.

This definition excluded assisted living facilities (ALFs) because, as CMS noted, these are institutions that are regulated by states, but are not reimbursed under the Medicaid program. State regulation of ALFs is not uniform across all states.

Enter COVID-19

Institutionalized seniors were at the center of the COVID-19 storm. The CDC has examined the prevalence of COVID-19 infection rates in ALFs and makes this observation:

By October 15, 2020, in 39 states with available data, 22% of ALFs reported one or more cases of COVID-19 among residents and staff members. Among ALF residents with COVID-19, 21% died, compared with 3% who died among the general population with COVID-19.

In September of 2020, the federal government extended funding to ALFs in Provider Relief Fund Phase 2 General Distribution, recognizing the vulnerability of these residents to the risk of the virus. Despite this increased risk, ALFs do not generally require residents to obtain their prescription drugs through a contracted LTC pharmacy, so many residents continue to rely on community retail establishments. LTC pharmacies have proven capabilities in managing complex drug regimens in the frail elderly population that are not routinely available to assisted living (and HCBS) residents.

A (Relatively) Simple Solution

Federal health agencies recognize the higher risk for viral infection for persons residing in assisted living and other congregate living arrangements within the United States. The vast majority of these residents are eligible for, and participants in, the Medicare drug benefit. The Dept. of Health and Human Services has extended provider relief to many of these organizations, recognizing the need to protect them during this pandemic.

It now seems reasonable to extend the benefits of the CMS LTC Guidance to all residents of congregate living arrangements, including ALFs, by requiring Part D sponsors to assure that these residents are afforded the LTC pharmacy services that have proven to be so beneficial to nursing home residents over the past 15 years. CMS can do this under its regulatory authority. It should.

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