What Does CMS’ Real-Time Benefit Tool Final Rule Mean for the Healthcare Industry?


What Does CMS’ Real-Time Benefit Tool Final Rule Mean for the Healthcare Industry?

January 2022 Update

The Beneficiary Real Time Benefit Tool (RTBT) final rule will require Part D plans to offer real-time comparison tools to enrollees starting January 1, 2023, so enrollees have access to real-time formulary and benefit information — including cost-sharing — to shop for lower-cost alternative therapies under their prescription drug benefit plan.

The implementation will be an essential step in improving the patient financial experience. Here is our take on the Who, What, Where, When, and Why of the CMS RTBT Final Rule.


The Quick and Dirty:

On May 23, 2019, the Trump Administration’s Centers for Medicare & Medicaid Services (CMS) published its Medicare Advantage and Part D Drug Pricing Final Rule, requiring that Medicare Part D sponsors — employers, unions, or insurance carriers that have an approved contract with the federal government to offer Medicare Advantage plans — implement an electronic real-time benefit tool (RTBT) capable of integrating with at least one prescriber’s electronic prescribing system or electronic health record.

While the rule states that sponsors must implement tools by January 1, 2021, CMS strongly encourages sponsors to start the implementation process prior to the 2021 deadline.

This rule has solidified the notion that providing prescription price transparency at the point of care is an essential step in improving the patient financial experience. In particular, the rule will benefit patients who want to understand their out-of-pocket drug costs, and providers who want to reduce time completing administrative tasks (like prior authorizations) and improve patient financial conversations.

Who Does the Final Rule (FR) Apply To?

The FR applies to Medicare Part D sponsors. These sponsors are typically private insurance plans who are contracted with the government to offer prescription drug coverage for millions of Americans. Those individuals who are enrolled in Medicare are able sign up for supplemental Part D insurance that offers coverage specifically for prescription medicines. Prior to Part D plans being available in 2003, Medicare recipients had little help when paying for retail drugs and therapeutics.

While the FR applies to organizations offering Medicare Part D coverage, it does not apply to healthcare prescribers or health systems (yet) due to the fact that there is no defined standard for RTBTs quite yet, and there is often a lack of trust in the data provided from RTBTs. CMS — and Arrive Health — believe prescribers will only use a RTBT if it is useful, reliable, and accurate, and that price transparency requirements will expand beyond Part D sponsors in the coming years.

What Is a RTBT and How Does a Plan Become Compliant?

A RTBT, which the industry often refers to as “Real-Time Benefit Check” or “Real-Time Prescription Benefit,” is an electronic prescription decision support tool that can help to significantly lower patient’s out-of-pocket expenses. NCPDP has developed their RTPB standard to conform to provider’s existing workflows and support interoperability at the highest level. These tools are most often used by doctors who prescribe drugs, and typically connect directly with payer and PBM data to present accurate patient coverage information in real-time. This allows for better prescriber-patient conversations, fewer call-backs for prior authorizations, and less prescription abandonment at the pharmacy. Early CMS data reveals that 45% of the time, RTBTs are able to save an average of $130 per patient.

According to CMS, compliance with the FR requires a sponsor to use a RTBT that includes (1) patient-specific utilization requirements (e.g. Prior Authorization or Step Therapy Requirements) that have not been satisfied at the time of prescribing; and (2) patient out-of-pocket costs at the patient’s selected pharmacy. Part D plans must ensure that the RTBT vendor that they select is “patient-specific, timely, and accurate.”

Where Does a Part D Sponsor Implement the RTBT?

A sponsor’s RTBT must be capable of integrating with at least one prescriber’s electronic prescribing (eRx) system or electronic health record (EHR). For example, Arrive Health’s RTBT presents drug cost information at more than 2,000 hospital systems and is integrated through numerous EHRs, so a sponsor who works with us would be compliant with this portion of the FR.

An “electronic prescribing system” allows healthcare providers to enter prescription information into a computer device – like a tablet, laptop, or desktop computer – and securely transmit the prescription to pharmacies using a special software program and connectivity to a transmission network. An electronic health record is a digital version of a patient’s paper chart and medical history. EHRs are real-time, patient-centered records that make information available instantly and securely to authorized users.

When Does the New FR Go Into Effect?

Originally, the FR was meant to go into effect January 1, 2020, but due to significant pushback from sponsors, the effective date was pushed back to January 1, 2021. However, CMS estimates 30–90% of Part D plans already have a RTBT, or the ability to easily implement one without a heavy lift or significant financial burden.

It is also worth noting that President Trump’s Hospital Transparency Final Rule will also go into effect January 1, 2021, although there is likely to be pushback from hospitals and other stakeholders before this Rule will go into effect.

Why Is an RTBT Necessary and Why Is Arrive Health the Best Option?

Providing prescription drug price transparency at the point of care has been an uphill battle for decades. But CMS’ Final Rule highlights the fact that implementing a RTBT is a critical step in improving patient financial conversations and lowering patients’ out-of-pocket costs. As an added benefit, CMS also anticipates that utilizing a RTBT will help to improve medication adherence since, on average, 30% of prescriptions do not get filled by patients, partly due to cost.

Now why might this rule be important if you are a hospital or health system? The FR reaffirms the industry trend towards price transparency. Not only have patients wanted this level of information for years, but now sponsors will be required to provide accurate pricing to their members. This requirement will surely be passed on to health systems that work with these sponsors, since patients covered by these sponsors will expect their doctors to provide accurate prescription pricing.

“CMS is delivering on price transparency, because patients have a right to know the cost of their healthcare services before they receive them,” said CMS administrator Seema Verma. The Rule “requires Part D plans to adopt tools that provide clinicians the information that they can discuss with patients on out-of-pocket costs for prescription drugs at the time a prescription is written.”

Arrive Health has been working closely with health systems, payers/PBMs, and EHR vendors to develop the most comprehensive real-time benefit check network in the market, bringing accurate out-of-pocket cost data into the hands of physicians. With more than 2,000 health systems using our tool and unparalleled payer coverage, we are well equipped to support plans and health systems as they prepare for implementation.

For more information about Arrive Health, its solutions, or innovative technologies, please contact a member of our team at contact@arrivehealth.com.

By Eric C. Naples, Esq.

Related content

Green Box
Green Box
Green Box
Click to access the login or register cheese