In January 2014, CMS PROPOSED ELIMINATING MEDICARE ACCESS TO MENTAL HEALTH TREATMENTS.
HR 3717, The Helping Families in Mental Health Act contains provisions to prevent that from happening.
In January 2014, CMS PROPOSED ELIMINATING MEDICARE ACCESS TO MENTAL HEALTH TREATMENTS
Section 502 of HR 3717, The Helping Families in Mental Health Act introduced in December 2013, contains provisions to prevent that from happening.
According to the Federal Register, on January 6, 2014, the Centers for Medicare and Medicaid Services (CMS) proposed to remove antidepressants and immunosuppressants from the protected class status they received under Medicare Part D in 2015. Some antipsychotics would be removed in 2016.
Background: According to the Council on Behavioral Health, in 2005, CMS directed that Part D formularies include all or substantially all drugs in six drug classes, including: antidepressant; antipsychotic; anticonvulsant; immunosuppressant (to prevent rejection of organ transplants); antiretroviral (for the treatment of infection by retroviruses, primarily human immunodeficiency virus (HIV); and antineoplastic. The Medicare Improvements for Patients and Providers Act created the six protected classes and the Affordable Care Act also defined them by name. Today, Medicare Part D plans must carry “all or substantially all” of the chemically distinct drugs in these categories on their formularies. For other categories, the plans can typically carry one brand-name drug and one generic drug.
Some say, this protection policy has ensured that Medicare recipients with mental illness — many of whom have severe and persistent mental illnesses — have access to the most appropriate drug without having to go through “fail-first” experiences or lengthy appeals and grievance processes to get the drug preferred by their doctor. Others claim the protected drugs are not better than other drugs and are simply ways for pharmaceutical companies to have ‘me-to’ drugs that are more profitable to them and more expensive to patients.
The proposal represents an effort to save money. However, the question is raised whether the impact of denying patients these specific treatments for their illness outweighs the minimal projected financial savings to Medicare Part D.
HOW HR3717 the Helping Families in Mental Health Crisis Act,” helps.
A provision of HR 3717, (Sec. 502) the “Helping Families in Mental Health Crisis Act” introduced by Rep. Tim Murphy in late 2013 specifically addressed this issue and would prevent these drugs from being removed from formularies.
SEC. 502. ACCESS TO MENTAL HEALTH PRESCRIPTION
DRUGS UNDER MEDICARE AND MEDICAID.
(a) COVERAGE OF PRESCRIPTION DRUGS USED TO TREAT MENTAL HEALTH DISORDERS UNDER MEDICARE.
Section 1860D–4(b)(3)(G)(i)(II) of the Social Security Act (42 U.S.C. 1395w–104(b)(3)(G)(i)(II)) is amended by inserting ‘‘, for categories and classes of drugs other than the categories and classes of drugs specified in subclauses (II) and (IV) of clause (iv),’’ before ‘‘exceptions’’.
(b) COVERAGE OF PRESCRIPTION DRUGS USED TO TREAT MENTAL HEALTH DISORDERS UNDER MEDICAID.
Section 1927(d) of the Social Security Act (42 U.S.C. 1396r–8(d)) is amended by adding at the end the following new paragraph:
ACCESS TO MENTAL HEALTH DRUGS.—
With respect to covered outpatient drugs used for1 the treatment of a mental health disorder, including major depression, bipolar (manic-depressive) disorder, panic disorder, obsessive-compulsive disorder, schizophrenia, and schizoaffective disorder, a State shall not exclude from coverage or otherwise restrict access to such drugs other than pursuant to a prior authorization program that is consistent with paragraph (5).’’
(Note: The preceding is a PRELIMINARY analysis by Mental Illness Policy Org and is subject to change. We note others feel differently and perhaps more research is needed. )
Link to text of HR 3717