Network based systems

CMS Offers Tighter Marketing and Network Adequacy for Medicare Advantage

Medicare Advantage plans may soon see stricter marketing guidelines and increased scrutiny of how Medicare revenues are spent if the Centers for Medicare and Medicaid Services finalize a proposed new rule.

Medicare Part D plans could face changes in how they can use savings from pricing agreements with pharmacies. CMS published Medicare Advantage 2023 regulation and Part D Thursday.

In addition, the proposed regulations include several proposals to improve the Medicare benefit for beneficiaries who are doubly eligible for Medicare and Medicaid.

CMS wants to strengthen oversight of third-party marketing organizations to eliminate what it calls deceptive marketing tactics in Medicare Advantage and Medicare Part D. The agency proposes to reinstate the requirement that plans include multilingual inserts in certain documents informing clients of free language and translation services. The rule would also codify registrant ID standards, requirements for exclusions from limited access to preferred cost-sharing pharmacies, and website requirements.

In addition, CMS wishes to strengthen the monitoring of the plan by instituting additional causes of refusal of a new contract or of an extension of the service area according to the previous performances of the operators. CMS proposes to add a star rating of 2.5 or less, bankruptcy or bankruptcy filings, and exceed the CMS threshold for compliance actions as a basis for denying claims.

Network adequacy standards would also see a boost. CMS proposes to require plan applicants to demonstrate that they will have a sufficient selection of contracted suppliers.

Part D plans can create agreements with pharmacies that do not meet certain criteria to pay less for drugs dispensed in those pharmacies. CMS wants to demand that these insurers apply any savings from these agreements to the negotiated price of the drugs. This would help beneficiaries share savings, according to CMS fact sheet. the agency is also proposing to redefine the negotiated price as the lowest eligible payment at a pharmacy, effective January 1, 2023.

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“We are committed to ensuring that older Americans and people with disabilities served by the Medicare program have access to quality, affordable health care, including prescription drugs and therapies,” CMS Administrator said , Chiquita Brooks-LaSure, in a statement. Press release. “The actions proposed today follow our guiding principles by improving health equity and improving access to prescription drugs.”

The agency wants to increase the accountability of plans for how they spend Medicare revenues. CMS is proposing to revert next year to the medical loss rate reporting requirements that were in use from 2014 to 2017. Medicare Advantage and Part D carriers are currently required to report the percentage of revenue they spend on patient care and healthcare. ‘improvement in quality, as well as the amount to be paid. revert to CMS if they don’t use at least 85% of the money for these activities. CMS also wants the Medicare Advantage and Part D organizations to report the underlying cost and revenue information needed to calculate and verify the medical loss ratio percentage and payout amount.

CMS is also proposing to require Medicare Advantage plans to report the amount they spend on additional benefits not available through traditional Medicare.

Additionally, CMS offers several proposals to improve the experiences of dual-eligible registrants with Medicare Advantage, starting with a requirement that all dual-qualifying special needs plans establish and maintain at least one registrant advisory committee. Insurers should consult advisory committees on matters related to health equity, CMS said.

The agency is also proposing to include questions on housing, food security and access to transportation in health risk assessments for special needs plans.

The agency wants to codify a system for states to require certain qualifying dual special needs plans to integrate their Medicare and Medicaid documents for registrants to give registrants a better understanding of their benefits.

CMS proposes to create an additional path for states with integrated care programs to require Medicare Advantage plans to establish contracts that only have qualifying dual special needs plans. The agency expects this to help highlight disparities between doubly eligible special needs plans and other Medicare Advantage plans and spur improvements for doubly eligible beneficiaries.

Finally, CMS wishes to clarify that the maximum disbursement limits for Medicare Advantage plans should be calculated based on the accumulation of all Medicare cost sharing in the benefits of the plans, whether Medicaid, the policyholder or an individual. other payer has covered the expense. CMS estimates that this would save state Medicaid agencies $ 2 billion and increase payments to providers serving eligible dual beneficiaries by $ 8 billion over 10 years.

Comments on the proposed rule are expected before March 7.

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