On April 29th, the Centers for Medicare & Medicaid Services (CMS) issued a final rule for the Medicare Advantage (MA) and Part D prescription drug programs that will improve experiences for dually eligible beneficiaries and provide greater transparency for the MA and Part D programs. “This rule improves the health care experience and affordability for millions of people with MA and Part D coverage, including dually eligible individuals, and provides needed support to populations often left behind.” said CMS Administrator Chiquita Brooks-LaSure.
This rule finalizes provisions to provide more affordable access to care for 53 million Americans enrolled in Medicare health or drug plans. First, Medicare Part D beneficiaries will see reduced out-of-pocket costs for prescription drugs starting in 2024, resulting from a new requirement that Part D plans pass along the price concessions received from pharmacies at the point of sale. Second, the rule clarifies policies to provide beneficiaries enrolled in MA plans uninterrupted access to necessary services during disasters and emergencies, like the COVID-19 pandemic.
Medicare and Medicaid are distinct programs that operate independently, which can sometimes result in fragmented care for the approximately 11 million individuals dually enrolled in Medicare and Medicaid. Dual eligibility is also a predictor of social risk and poor health outcomes. Many dually eligible individuals experience challenges such as housing insecurity and homelessness, food insecurity, lack of access to transportation, and low levels of health literacy.
The final rule will help close health disparities by delivering person-centered integrated care that can lead to better health outcomes for enrollees and improve the operational functions of these programs. The rule also requires all MA special needs plans to annually assess certain social risk factors for their enrollees because identifying social needs is a key step to delivering person-centered care.
Plans will be required to include a multi-language insert in all required documents provided to enrollees. In addition, CMS is closing a loophole for dually eligible MA enrollees who have high medical costs that exceed the maximum out-of-pocket limit established by the MA plan. This loophole had resulted in lower payment to providers serving dually eligible MA enrollees than providers serving non-dually eligible MA enrollees.
The rule also promotes sustainability of the Medicare program. CMS is reinstating medical loss ratio reporting requirements and expanding reporting requirements for MA supplemental benefits. This will improve transparency into MA and Part D plans’ underlying costs, revenue, and supplemental benefits, which will benefit beneficiaries and taxpayers.
“Fiscal stewardship is a central principle of the work we do every day,” said CMS Deputy Administrator and Director of the Center for Medicare Dr. Meena Seshamani. “As responsible stewards of the program, this rule enables us to learn more about how the Medicare dollar is being spent on certain Medicare Advantage benefits, such as housing, food, and transportation assistance, in order to better understand how we can most effectively support the health and social needs of people with Medicare.”
The rule also strengthens CMS’ role as a responsible steward of the Medicare program by leveraging its authority to limit MA and Part D plans’ ability to expand existing contracts and/or enter into new contracts if they have previously been poor performers. Additionally, CMS is improving application standards and oversight of MA applicants’ provider networks to ensure enrollees will have access to a sufficient network of providers before CMS will approve for the first time or allow an existing MA contract to expand. CMS will also protect Medicare beneficiaries by holding plans accountable to detect and prevent the use of confusing or potentially misleading marketing tactics by third-party marketing organizations.
Read original article in cms.gov/newsroom
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