Medicare Part D/IRA PAWH Implications Comments

Dear Sarah Bourland,

Thank you for the insightful briefing provided by the HHS Office of Intergovernmental and External Affairs on the New 2024 Inflation Reduction Act Benefits. The attached handout is a valuable resource, and I am (and we at HealthHIV are) grateful for the effort to disseminate such important information. It will undoubtedly assist in efforts to inform the public about the relief available from drug costs under the Inflation Reduction Act. I would also like to uplift a point of interest regarding the evolving landscape of Medicare Part D—especially the Stand-alone Prescription Drug Plans (PDPs). 

As we step into 2024 and especially into 2025, we’re observing notable changes in the benchmark availability and structure of some plans. The reduction in the number of PDP options, coupled with the increasing costs, presents a challenging scenario for Medicare beneficiaries, particularly for older individuals living with conditions like HIV—and one we are thankful you are working to address through the IRA. “In response to these changes, it’s important to recognize that Part D plans are, and will continue to be, significantly influenced by the Inflation Reduction Act (IRA). This influence raises critical questions about the accessibility and affordability of essential medications for beneficiaries. Additionally, the introduction of upper payment limits and affordability reviews by state-level Prescription Drug Affordability Boards may impact clinical decision-making. These boards could potentially influence how fully FDA-approved medications, aligned with HHS treatment guidelines, are utilized. With fewer PDP options and increasing premiums, ensuring that the needs of vulnerable groups are met remains a critical concern. The shift towards Medicare Advantage drug plans (MA-PDs) and the potential implications of the new out-of-pocket spending cap set to take effect in 2025 also warrant close attention. These developments could significantly impact the landscape of Medicare Part D, and it’s essential that we continue to monitor and address these evolving challenges to maintain comprehensive and affordable healthcare coverage for all Medicare beneficiaries.

As we navigate the evolving landscape of Medicare Part D, assessing the impacts on beneficiaries, especially those dependent on specific treatments, becomes crucial. To this end, HealthHIV’s Third Annual State of Aging with HIV™ National Survey emerges as a key resource. 

It provides vital insights into the experiences and needs of Older Persons with HIV in the U.S., informing our understanding of the challenges they face, including healthcare costs.

The primary health services research landscape survey, which you can find here, reflects on the experiences and challenges of Older Persons with HIV in the U.S., including those related to healthcare costs. The feedback from nearly a thousand participants highlights the urgent need to maintain comprehensive coverage and affordable costs for all Medicare beneficiaries. 

In April 2023, the Office of HIV/AIDS Housing introduced a webinar series tailored to the specific needs of the aging HIV community, addressing topics like community resource access and housing solutions that support aging in place. This series included a focus on the logistics and costs associated with aging comfortably in one’s own home.

Likewise, our Second Annual State of LGBTQ Health National Survey aimed to assess the healthcare status of LGBTQ communities. Key findings from this survey included challenges related to cost constraints and insurance concerns.

Your insights and continued dialogue in this space would be invaluable. Any further information or collaboration on these crucial matters is always welcome, and thank you for your commitment to improving healthcare access and affordability.

Community Conversations, Messaging | Implications to Older Persons with HIV

The Medicare Part D plans for 2024 exhibit several key changes. In 2024, Medicare beneficiaries have a choice of nearly 60 Part D drug coverage plans, including a reduced number of stand-alone prescription drug plans (PDPs) and an increased number of Medicare Advantage drug plans (MA-PDs). There’s a notable decrease in “benchmark” PDPs, which are crucial for beneficiaries receiving Part D Low-Income Subsidies (LIS), with only three such plans available.

The average projected monthly premium for PDPs is estimated to be $48, a significant increase from the previous year, primarily due to changes in the Inflation Reduction Act, including a new cap on out-of-pocket spending. Monthly premiums for PDPs are substantially higher compared to MA-PDs, with PDP enrollees facing higher cost-sharing for branded drugs.

The number of available PDPs has reached its lowest since the initiation of Part D, affecting the choices available to beneficiaries, especially those in traditional Medicare. This trend, alongside the rising costs and increasing availability of low- or zero-premium MA-PDs, may further shift enrollment towards Medicare Advantage plans in the future. These changes highlight the evolving landscape of Medicare Part D and the need for ongoing policy considerations to ensure competitive pricing and availability of plans.

Medicare Part D Stand-alone Prescription Drug Plans (PDPs) are health insurance plans offered by private companies, approved by Medicare, to provide prescription drug coverage for beneficiaries who are enrolled in traditional Medicare. These plans cover a range of prescription medications, often with varying costs and formularies. Benchmark Plans, a subset within PDPs, are specifically designed for beneficiaries receiving the Part D Low-Income Subsidy (LIS). These Benchmark Plans are available to LIS enrollees with no monthly premium. Each year, certain PDPs qualify as Benchmark Plans based on their premium costs being below a regionally determined threshold, enabling low-income beneficiaries to access necessary prescription medications without additional financial burden.

Older Persons with HIV Considerations

The evolving Medicare Part D landscape, characterized by fewer PDP options and rising costs, could present challenges for older people living with HIV, necessitating careful plan selection and potential policy adjustments to safeguard their access to essential HIV medications.

The reduction in the number of available Medicare Part D Stand-alone Prescription Drug Plans (PDPs) and the concurrent rise in costs could significantly impact older people living with HIV, particularly those in traditional Medicare. Key implications include:

1. Limited Choices: With fewer PDP options, older HIV patients might find it more challenging to find plans that cover specific HIV medications or offer the most favorable cost-sharing terms for their treatment regimens.
2. Increased Costs: The rising costs of PDPs could impose a financial burden on older HIV patients, especially those without Low-Income Subsidies, potentially affecting their ability to afford necessary medications.
3. Shift Towards Medicare Advantage Plans (MA-PDs): The growing availability of low- or zero-premium MA-PDs might encourage a shift from PDPs to MA-PDs. While this could be financially beneficial, MA-PDs often have network restrictions, which might limit access to preferred HIV specialists or specific treatments.
4. Need for Careful Plan Selection: Older HIV patients will need to be more vigilant in selecting the right plan, considering factors like drug formularies, network restrictions, and out-of-pocket costs to ensure uninterrupted and affordable access to their HIV treatments.
5. Impact on Treatment Adherence: Any disruption in medication access or increased financial strain could impact adherence to HIV treatment regimens, which is crucial for managing the disease effectively.
6. Policy Implications: This situation underscores the need for policy interventions to ensure that the Medicare Part D landscape continues to provide affordable and comprehensive drug coverage options for older patients with chronic conditions like HIV.

Older Persons with HIV IRA Considerations

The IRA’s redesign of Medicare Part D in PY 2025 could lead to beneficial changes for older persons with HIV, particularly in reducing out-of-pocket expenses. However, it also necessitates a vigilant approach to understanding evolving plan offerings, formulary changes, and the overall impact on the accessibility and affordability of HIV medications.

1. New Out-of-Pocket Cap: The IRA introduces a new out-of-pocket spending cap for beneficiaries. For older persons with HIV, this can significantly reduce the financial burden associated with their medication costs, especially for those on high-cost antiretroviral therapies.
2. Manufacturer Discounts: The IRA mandates new manufacturer discounts for Medicare, which could potentially lower the cost of HIV medications. However, the specifics of these discounts and their direct impact on pricing for HIV drugs remain to be seen.
3. Increased Plan Liabilities: Health plans will face increased financial responsibilities. This might lead to changes in plan offerings, potentially affecting how HIV medications are covered. Older HIV patients will need to carefully review plan changes to ensure their medications remain covered and affordable.
4. Changes in Patient Behavior: With the redesign, older HIV patients might alter their approach to medication adherence and utilization, knowing their out-of-pocket expenses are capped. This could lead to better adherence to HIV treatment regimens, improving health outcomes.
5. Plan Reactions and Formulary Design: Part D plans may revise their formulary designs and utilization management strategies in response to the IRA changes. This could affect which HIV medications are preferred or have lower cost-sharing, impacting treatment choices for older HIV patients.
6. Contracting Discussions Impact: Contracting negotiations between manufacturers and Part D plans for PY 2025 will take these changes into account. This could influence the availability and pricing of HIV drugs within Part D plans. Older HIV patients may see shifts in which medications are more economically accessible through their plans.
7. Navigating Plan Choices: Given these changes, it’s essential for older persons with HIV to stay informed and actively review their Medicare Part D plans during open enrollment to ensure optimal coverage for their HIV treatment needs.

---