CDC Issues New Guidelines on Opioid Prescription and Pain Management Treatment

The Centers for Disease Control and Prevention (“CDC”) recently released updated clinical practice guidelines (the “Guidelines”) on opioid prescribing and providing pain care for adults with chronic pain.

This update came as a result of a systematic review to evaluate and reassess the 2016 CDC Opioid Prescribing Guideline as new evidence became available. According to the CDC, the new evidence reviews conducted on behalf of the CDC affirmed the appropriateness of the recommendations in the 2016 CDC Opioid Prescribing Guideline for using opioids to treat chronic pain and, based on that review, the CDC determined that an update to the 2016 CDC Opioid Prescribing Guideline was warranted.

This updated clinical practice guideline also includes a new topline recommendation for patients who are already receiving ongoing opioid therapy for pain. The CDC specifically described how “the clinical practice guideline outlines how clinicians and patients should work together in assessing the benefits and risks of continued opioid use and if or when to taper opioids to a lower dosage or discontinue opioids altogether in accordance with the HHS Tapering Guide.”

The CDC has released a Fact Sheet on the updated Guidelines.

Proposed Rule Updating Versions of the Retail Pharmacy Standards for Electronic Transactions Under HIPAA

The Department of Health and Human Services (“HHS”) issued a Proposed Rule on November 9, 2022 which seeks to adopt updated versions of the retail pharmacy standards for electronic transactions adopted under the Administrative Simplification subtitle of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). The Proposed Rule would also broaden the applicability of the Medicaid pharmacy subrogation transaction to all health plans.

According to HHS, “These updated versions would be modifications to the currently adopted standards for the following retail pharmacy transactions:

• health care claims or equivalent encounter information;
• eligibility for a health plan;
• referral certification and authorization; and
• coordination of benefits.”

HHS further provides that “industry stakeholders reported that there is a need to expand the use of the current Medicaid Subrogation Implementation Guide Version 3.0 (Version 3.0) beyond Medicaid agencies, and the use of a subrogation standard that would apply to other payers would be a positive step for the industry.”

Per HHS, “Subrogation” occurs when one payer has paid a claim that is subsequently determined to be the responsibility of another payer, and the first payer seeks to recover the overpayment directly from the proper payer. Furthermore, according to HHS, HIPAA regulations currently require only Medicaid agencies to use Version 3.0 in conducting the Medicaid pharmacy subrogation transaction.

Under the Proposed Rule, all health plans would be required to use the Pharmacy Subrogation Implementation Guide for Batch Standard, Version 10, to transmit pharmacy subrogation transactions. According to HHS, this would allow better tracking of subrogation efforts and results across all health plans, and support cost containment efforts.

Covered entities should be aware that the Proposed Rule would require covered entities to comply 24 months after the effective date of the final rule. According to the Proposed Rule, small health plans would have 36 months after the effective date of the final rule to comply.

CMS has issued a Fact Sheet on the Proposed Rule.

“Family Glitch” Fixed by IRS

The Internal Revenue Service’s (“IRS”) Final Rule takes effect on December 12, 2022 and will remove the so-called “Family Glitch” problem with the Affordable Care Act Marketplace coverage. The “Family Glitch” is a problem under the ACA whereby if one family member has an affordable offer of coverage from an employer, then all family members are ineligible for premium tax credits to purchase Marketplace coverage, even if the cost of coverage for the whole family is greater than 9.83 percent of family income.

The regulations will remove the applicability of the Family Glitch. HHS aims to implement the rules for the 2023 plan year and will provide training on the new rules to agents, brokers, and other assisters so applicants will better understand their options before enrolling, including the trade-offs if applicants are considering split coverage.

The White House released a Fact Sheet on this update.