What “Meaningful Difference” Means for Medicare Patient Access

November 13, 2014

by Amanda Conschafter, blog editor

It’s Medicare open enrollment time for America’s seniors. Once again, the Centers for Medicare and Medicaid Services require Part D plan sponsors to offer distinct coverage options – those demonstrating a “meaningful difference” from one another. CMS defines that difference with a specific out-of-pocket dollar threshold. But to meet these thresholds, plan sponsors may limit coverage to necessary medications based upon their cost. CMS means to make Part D offerings clearly defined for seniors. But does the meaningful difference policy translate into well-defined options – or restricted access to vital medicines?

Instituted in 2010, the meaningful difference policy may require plan sponsors to trim benefits to meet dollar threshold restrictions. That may well limit seniors’ access to medications, including those on CMS’ list of beneficiaries’ most commonly used prescription drugs.

The limitations disproportionately affect lower-income seniors, who are more likely to choose the basic coverage plans due to financial considerations. Dual-eligible seniors, who receive benefits through both Medicaid and Medicare, are often auto-enrolled in the basic plans by CMS. Both groups may find their access to prescription drugs limited as a result. And for dual-eligible seniors, who may suffer from multiple conditions concurrently, access to medication can be particularly crucial.

Earlier this year, CMS issued a proposed rule that suggested eliminating out-of-pocket calculator use for 2016 plans. The proposed rule also suggested limiting plan sponsors to two prescription drug plan offerings – one basic and one enhanced – per geographic region. Avalere Health reported that the two-plan limit could affect 7.4 million beneficiaries by eliminating plans, altering benefits or increasing premiums.

In the final May 2014 rule, however, CMS opted not to implement these strategies. Instead, the agency plans to conduct further analysis on the impact of meaningful difference requirements. Thus, as beneficiaries enroll this month, policymakers continue to consider whether meaningful difference requirements make choices simpler – or prescription drug access more difficult – for America’s seniors.

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