Commission Recommendations
MedPAC makes recommendations to the Congress and to the Secretary of Health and Human Services on issues affecting the administration of the Medicare program. With its recommendations, the Commission strives to improve the delivery of care, while ensuring financial stability and maximizing value for the program. After extensive analysis and evaluation, our recommendations are discussed and voted on by Commissioners in our public meetings. Recommendations are typically published in two main reports, released in March and June of each year.
| Recommendations | Topic(s) | Publication |
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Improving Medicare’s policies for separately payable drugs in the hospital outpatient prospective payment system (1)The Congress should direct the Secretary to modify the pass-through drug policy in the hospital outpatient prospective payment system so that it: includes only drugs and biologics that function as supplies to a service and applies only to drugs and biologics that are clinically superior to their packaged analogs. |
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Improving Medicare’s policies for separately payable drugs in the hospital outpatient prospective payment system (2)The Secretary should specify that the separately payable non-pass-through policy in the hospital outpatient prospective payment system applies only to drugs and biologics that are the reason for a visit and meet a defined cost threshold. |
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Medicare vaccine coverage and paymentThe Congress should: cover all appropriate preventative vaccines and their administration under Part B instead of Part D without beneficiary cost sharing and modify Medicare’s payment rate for Part B-covered preventative vaccines to be 103 percent of wholesale acquisition cost, and require vaccine manufacturers to report average sales price data to CMS for analysis. |
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Realigning incentives in Medicare Part D (1)The Congress should make the following changes to the Part D prescription drug benefit: Below the out-of-pocket threshold: Eliminate the initial coverage limit. Eliminate the coverage-gap discount program. Above the out-of-pocket threshold: Eliminate enrollee cost sharing. Transition Medicare’s reinsurance subsidy from 80 percent to 20 percent. Require pharmaceutical manufacturers to provide a discount equal to… Read more » |
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Realigning incentives in Medicare Part D (2)Concurrent with our recommended changes to the benefit design, the Congress should: Establish a higher copayment amount under the low-income subsidy for nonpreferred and nonformulary drugs. Give plan sponsors greater flexibility to manage the use of drugs in the protected classes. Modify the program’s risk corridors to reduce plans’ aggregate risk during the transition to… Read more » |
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Realigning incentives in Medicare Part D (3)Concurrent with our recommended changes to the benefit design, the Secretary should: Allow plans to establish preferred and nonpreferred tiers for specialty-tier drugs. Recalibrate Part D’s risk adjusters to reflect the higher benefit liability that plans bear under the new benefit structure. |
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The Medicare prescription drug program (Part D): Status reportThe Congress should change Part D’s coverage-gap discount to: require manufacturers of biosimilar products to pay the coverage-gap discount by including biosimilars in the definition of “applicable drugs” and exclude biosimilar manufacturers’ discounts in the coverage gap from enrollees’ true out-of-pocket spending. |
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Medicare Part B drug payment policy issuesThe Congress should change Medicare’s payment for Part B drugs and biologicals (products) as follows: Modify the average sales price (ASP) system in 2018 to: require all manufacturers of products paid under Part B to submit ASP data and impose penalties for failure to report. reduce wholesale acquisition cost (WAC)-based payment to WAC plus 3… Read more » |
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Improving Medicare Part D (1)The Congress should change Part D to: transition Medicare’s individual reinsurance subsidy from 80 percent to 20 percent while maintaining Medicare’s overall 74.5 percent subsidy of basic benefits, exclude manufacturers’ discounts in the coverage gap from enrollees’ true out-of-pocket spending, and eliminate enrollee cost sharing above the out-of-pocket threshold. |
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Improving Medicare Part D (2)The Congress should change Part D’s low-income subsidy to: modify copayments for Medicare beneficiaries with incomes at or below 135 percent of poverty to encourage the use of generic drugs, preferred multisource drugs, or biosimilars when available in selected therapeutic classes; direct the Secretary to reduce or eliminate cost sharing for generic drugs, preferred multisource… Read more » |
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