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CMS Proposes New Rules for Medicare Advantage and Part D

Last week, CMS announced proposed rules seeking to increase consumer protections and reduce health care disparities in Medicare Advantage (MA) and Part D, with a strong emphasis on individuals who are dually eligible for Medicare and Medicaid.  Below is a summary of the proposed changes

Medicare Advantage

  • Make technical changes to the 2023 Part C Star Ratings for certain measures collected through the Health Outcomes Survey (HOS) to account for the impact of the COVID-19 public health emergency.

  • Use past performance as a reason for denying a new contract or service area expansion (e.g., Star Ratings at 2.5 or lower, bankruptcy filings, or exceeding a CMS designated threshold for compliance actions). 

  • Require plan sponsors to demonstrate that they have a sufficient network of contracted providers before CMS will approve an application for a new or expanded MA plan.

  • Strengthen marketing and communications oversight to detect and prevent the use of deceptive marketing tactics.

  • Update timeframes and standards associated with disasters and emergencies to ensure beneficiaries have uninterrupted access to needed services.

  • Reinstate Medical Loss Ratio (MLR) reporting requirements related to the underlying cost and revenue information needed to calculate and verify the MLR.

Part D Price Concessions

  • Require Part D plans to apply all price concessions received from network pharmacies at the point-of-sale to reduce the beneficiary’s out-of-pocket costs at the pharmacy counter.

Emphasis on Increasing Protections for Dually-Eligible Beneficiaries

  • Require D-SNPs to establish and maintain one or more enrollee advisory committees and consult with the committees on issues related to health equity.

  • Require SNP Health Risk Assessments include specific standardized questions on housing stability, food security, and access to transportation, which are known to be important contributors to overall health.

  • Expand the unified grievance and appeals processes to include more D-SNPs.

  • Establish a mechanism by which states can require certain D-SNPs to use integrated materials to make it easier to understand the full scope of Medicare and Medicaid benefits available through the D-SNPs.

  • Allow certain states with integrated care programs to require MAOs establish a contract that only includes one or more D-SNPs, to allow for Star Ratings that reflect the D-SNP’s performance.

  • Require that the maximum out-of-pocket limit be calculated based on the accrual of all Medicare cost-sharing in the plan benefit, whether that Medicare cost-sharing is paid for by the beneficiary, Medicaid, or other secondary insurance, or remains unpaid because of state limits on the amounts paid for Medicare cost-sharing and dually eligible individuals’ exemption from Medicare cost-sharing.

  • Require all fully-integrated dual eligible special needs plans (FIDE SNPs), to have exclusively aligned enrollment beginning in 2025 (i.e., limit enrollment to individuals in the affiliated Medicaid MCO) and cover Medicaid home health, durable medical equipment, and behavioral health services through a capitated contract with the state Medicaid agency.

©1994-2023 Mintz, Levin, Cohn, Ferris, Glovsky and Popeo, P.C. All Rights Reserved.National Law Review, Volume XII, Number 11

About this Author

Bridgette A. Keller, health system administration LAWYER, Mintz

Bridgette applies her experience in health system administration and ethics in health care to her health law practice. Bridgette advises health care providers, ACOs, health plans, PBMs, and laboratories on a variety of regulatory, fraud and abuse, and business planning matters.

With a background in health care operations, Bridgette is able to provide clients with practical insight that includes a focus on the business implications of health care enforcement defense activities, internal investigations, regulatory compliance, and fraud and abuse...