Medicaid Redeterminations Will Increase Use of Patient Support

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Medicaid redeterminations will bring changes to individual prescription drug access. Manufacturers should consider the impact on patient support programs.

Since the public health emergency (PHE) began in March 2020, states have provided continuous Medicaid enrollment to beneficiaries while receiving an enhanced Federal Medical Assistance Percentage (FMAP) of 6.2 additional percentage points. In December 2022, however, the Consolidated Appropriations Act established that continuous enrollment may end on March 31, 2023, and that states may begin disenrollments on April 1, 2023. States will have 12 months to initiate and an additional 2 months to complete the redetermination process (i.e., the process state Medicaid agencies use to redetermine beneficiary eligibility), though they may elect to complete the process sooner.

As of November 2022, 91.8 million individuals were enrolled in Medicaid and the Children’s Health Insurance Program (CHIP), an increase of 21.1 million beneficiaries since February 2020. According to the Urban Institute, around 18 million people could lose Medicaid coverage as redeterminations begin and continue through the next year. The study estimated that most of those individuals will transition to other forms of insurance, with around 9.5 million moving to employer-sponsored insurance, 3.2 million children moving to CHIP, nearly 1 million gaining coverage through state exchanges, and nearly 4 million becoming uninsured.

As individuals move into new sources of coverage, they may experience limited access to products that were covered under Medicaid with minimal cost sharing if their new coverage includes higher deductibles, copayments, or coinsurance. Higher cost sharing is likely to affect individuals’ ability to afford their medications. Increased cost sharing, especially as individuals move coverage mid-benefit year, could lead to an increase in patients’ need for manufacturer cost-sharing assistance or free drug programs.

As redeterminations begin, manufacturers should consider how shifts in coverage will alter their current commercial patient support programs (PSPs) and free drug programs.

Medicaid Redetermination Impact on PSP Manufacturer Considerations
Affordability and Increase in Demand
  • Collaborate with program vendors to develop risk assessments for specialty products, products with launch dates in the last 3 years, and increased Medicaid use since the PHE went into effect.
  • Identify potential program design changes (e.g., eligibility updates, funding allocation) to address dynamic patient needs in the coming months.
Volume of Requests
Through the Hub
  • Prepare for a potential increase in cost-sharing assistance and free drug program enrollment through Hub support.
  • Ensure Hub has the capacity for updated prescription volume and increased need for educational support for patients.
Copay Adjustment Programs
  • Assess brand/portfolio risk and identify tailored program strategies to mitigate patient affordability challenges (e.g., mode of support, eligibility criteria) created by copay accumulators and maximizer programs.
Access Support
  • Develop additional wrap-around support services (e.g., insurance counseling, transportation) that are tailored to the patient population to account for shifts in healthcare coverage.

In addition to the shifts in coverage brought by upcoming Medicaid redetermination, manufacturers and other stakeholders must consider the impact that the Inflation Reduction Act’s capped Medicare Part D patient out-of-pocket costs may have on foundation or charity support needs. For example, the need for free drug programs may decline, but Medicare-age individuals may face new access challenges due to potential changes to formulary management.

With hands-on policy and market access experience from the payer, manufacturer, and third-party vendor perspectives, Avalere helps clients understand the evolving landscape of patient support, models the impacts of these policy changes, and identifies solutions to maximize patient access. To learn how Avalere can help your organization respond to—or shape—the evolving patient support program landscape, connect with us.

Webinar | A Closer Look at Patient Support Avalere experts explored how potential implications of the Inflation Reduction Act (IRA)’s out-of-pocket cap, in addition to other key regulatory and policy activities shaping benefit design and patient cost-share (e.g., EHB), could impact patient commercial and foundation assistance. Learn More
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