On April 5, 2023, the U.S. Department of Health and Human Services (HHS), through the Centers for Medicare & Medicaid Services (CMS) issued a final rule that revises many of the Medicare Advantage (MA or Part C) & Medicare Prescription Drug Benefit (Part D) provisions. These revisions seek to implement changes related to Star Ratings, marketing and communications, health equity, provider directories, coverage criteria, prior authorization, network adequacy, and other programmatic areas. The new rules should also promote health “equity” and implement a key provision of the Inflation Reduction Act. It is reported that these changes will improve access to affordable prescription drug coverage for an estimated 300,000 low-income and disadvantaged individuals.
In the past few months, the Department has taken a series of actions to ensure the Medicare Advantage program works for people with Medicare and that private insurance companies are held accountable for providing quality coverage and care. In February, CMS finalized a rule to start recovering improper payments made to Medicare Advantage plans through audits for the first time since 2007. Recovering these improper payments and returning this money to the Medicare Trust Funds will protect the fiscal sustainability of Medicare and allow the program to better serve seniors and people with disabilities. Last week, CMS finalized policies in the 2024 Medicare Advantage and Part D Rate Announcement to improve payment accuracy and ensure taxpayer dollars are appropriately safeguarded and well-spent. “At HHS, we put seniors and people with disabilities first,” said HHS Secretary Xavier Becerra. “That is exactly what we are doing today. In our latest effort to strengthen Medicare and hold insurance companies accountable, we are putting protections in place so that Medicare Advantage works for beneficiaries, and they get the quality care they deserve.” CMS Administrator Chiquita Brooks-LaSure chimed in with “With this final rule, CMS is putting in place new safeguards that make it easier for people with Medicare to access the benefits and services they are entitled to, while also strengthening the Medicare Advantage and Part D programs.” Adding her input into this word salad, Dr. Meena Seshamani, CMS Deputy Administrator and Director of the Center for Medicare said “People with Medicare deserve to have access to accurate information when making coverage choices, and to be able to get the care they need without excessive burden or delays. The commonsense policies in this rule further our goals to advance health equity, improve access to care, and drive high-quality, whole-person care.”
Another area that these revisions implement are rules cracking down on misleading marketing schemes. The final rule includes changes to protect people exploring Medicare Advantage and Part D coverage from confusing and potentially misleading marketing practices. Ads will be prohibited if they do not mention a specific plan name, or if they use the Medicare name, CMS logo, and products or information issued by the Federal Government, including the Medicare card, in a misleading way. Further, the final rule strengthens accountability for plans to monitor agent and broker activity.
Included in this package are important protections regarding utilization management policies and the final rule clarifies clinical criteria guidelines to ensure people with Medicare Advantage receive access to the same medically necessary care they would receive in Traditional Medicare. The rule streamlines prior authorization requirements and reduces disruption for enrollees by requiring that a granted prior authorization approval remains valid for as long as medically necessary to avoid disruptions in care. This will require Medicare Advantage plans to annually review utilization management policies and require denials of coverage based on medical necessity be reviewed by health care professionals with relevant expertise before a denial can be issued. These changes will help ensure enrollees have consistent access to medically necessary care while also maintaining medical management tools that emphasize the important role Medicare Advantage plans play in coordinating this care.
Noteworthy, keeping with their theme of “equity”, this Administration is advancing health equity and driving quality in health coverage by establishing a health equity index in the Star Ratings program. The Star Rating will now reward Medicare Advantage and Medicare Part D plans that provide excellent care for underserved populations. Populations of interest are those with certain social risk factors. These include people who identify as lesbian, gay, bisexual or other diverse identities, people who identify as transgender or nonbinary or other diverse gender identities and people with limited English proficiency or reading skills. Also included in this list are traditional ethnic, cultural, racial or religious minorities, those who live in rural areas and those adversely affected by persistent poverty or inequality. Plans will be required to provide culturally competent care to an expanded list of populations and to improve equitable access to care for those with limited English proficiency, through newly expanded requirements for providing materials in alternate formats and languages. In addition, CMS includes an additional rule for the removal of Star Ratings measures and removes the 60 percent rule that is part of the adjustment for extreme and uncontrollable circumstances. The final rule balances patient experience/complaints measures, access measures, and health outcomes measures in the Star Ratings program to focus more effectively both on patient-centric care and on improving clinical outcomes.
Among the many things this final rule does is that it expands eligibility for the full low-income subsidy benefit (also known as “Extra Help”) to individuals with incomes up to 150% of the federal poverty level who meet eligibility criteria. This change will begin January 1, 2024, and it will provide the full low-income subsidy to those who would currently qualify for the partial low-income subsidy. As a result of this change, eligible enrollees will have no deductible, no premiums (if enrolled in a “benchmark” plan), and fixed, lowered copayments for certain medications under Medicare Part D.
This article does not cover all that was implemented in these rules changes, so if you need more information or want to get additional clarity on what was involved, go to CMS.gov website at https://www.cms.gov/newsroom/fact-sheets/2024-medicare-advantage-and-part-d-final-rule-cms-4201-f.