Proposed rule also implements provision of President Biden’s Inflation Reduction Act to lower prescription drug costs for low-income people with Medicare
On December 14, 2022 the U.S. Department of Health and Human Services (HHS), through the Centers for Medicare & Medicaid Services (CMS), proposed a rule to strengthen Medicare Advantage and Medicare Part D prescription drug coverage for the tens of millions of people who rely on the programs for health care coverage. The proposed rule improves protections for people with Medicare, expands access to behavioral health care, and promotes equity in coverage. The proposed rule also implements a key provision of the Inflation Reduction Act to make prescriptions drugs more affordable for approximately 300,000 low-income individuals who will benefit in 2024.
“We are taking feedback from thousands of Americans and turning it into concrete action to strengthen Medicare for the millions of Americans who rely on it,” said HHS Secretary Xavier Becerra. “From streamlining prior authorization to cracking down on misleading marketing, we are committed to ensuring that everyone can have peace of mind and get the health care they need.”
“We continue working tirelessly to implement President Biden’s Inflation Reduction Act. Yesterday, thanks to the new law, we are taking action to lower costs and expand access to affordable prescription drug coverage for hundreds of thousands of people with Medicare, including communities of color and those living on fixed incomes,” the Secretary continued. “CMS released a proposed rule today that takes important steps to hold Medicare Advantage plans accountable for providing high quality coverage and care to enrollees,” said CMS Administrator Chiquita Brooks-LaSure. “The rule also strengthens Medicare prescription drug coverage and implements an important provision of the Inflation Reduction Act to help more people with Medicare who have modest incomes afford their prescriptions.”
A July 2022 Request for Information on Medicare Advantage drew almost 4,000 comments regarding improvements to the program. We thank stakeholders for their thoughtful feedback, and the policies in this proposed rule are informed by the feedback received.
In this rule, CMS proposes significant changes to strengthen protections for people enrolled in or seeking coverage from Medicare Advantage plans or Medicare Part D prescription drug plans, including through improvements to prior authorization, coverage guidelines, and plan marketing requirements. The rule proposes clarifications and revisions to regulations governing when and how Medicare Advantage plans develop and use coverage criteria and utilization management policies to ensure Medicare Advantage enrollees receive the same access to medically necessary care they would receive in Traditional Medicare. The rule also proposes policies to streamline prior authorization requirements and reduce disruption for enrollees. It does this by requiring that a granted prior authorization approval remain valid for an enrollee’s full course of treatment, requiring Medicare Advantage plans to annually review utilization management policies, and requiring coverage determinations be reviewed by professionals with relevant expertise. These proposed policies complement proposals in CMS’ recently announced Advancing Interoperability and Improving Prior Authorization Processes Proposed Rule (CMS-0057-P).
Additionally, the proposed rule focuses on protecting people exploring Medicare Advantage and Part D coverage from confusing and potentially misleading marketing while also ensuring access to accurate and necessary information to make coverage choices. The proliferation of certain television advertisements generically promoting Medicare Advantage enrollment has been a topic of concern. To address this, CMS proposes to prohibit ads that do not mention a specific plan name as well as ads that use words and imagery that may be confusing, or use language or logos in a way that is misleading, confusing, or misrepresents the plan. CMS also proposes to codify guidance protecting people with Medicare or exploring Medicare coverage from misleading marketing and ensure they are not pressured into enrolling into plans that may not best meet their needs. Further, CMS is proposing to strengthen the role of plans in monitoring agent and broker activity.
“People exploring Medicare coverage options deserve peace of mind that they are receiving honest, transparent, and accurate information about health coverage options and have access to the care they need. These proposed protections are commonsense and critical to the physical, mental, and financial stability of millions of people who choose a Medicare coverage option each year,” said Dr. Meena Seshamani, CMS Deputy Administrator and Director of the Center for Medicare.
CMS remains committed to emphasizing the invaluable role that access to behavioral health plays in whole person care. In line with CMS’ Behavioral Health Strategy and the Administration’s strategy to address the national mental health crisis, CMS proposes to strengthen behavioral health network adequacy by adding clinical psychologists, licensed clinical social workers, and prescribers of medication for opioid use disorder to the list of evaluated specialties. CMS also proposes new minimum wait time standards for behavioral health and primary care services and more specific notice requirements from plans to patients when these providers are dropped from their networks. Finally, CMS proposes to require most types of Medicare Advantage plans include behavioral health service in care coordination programs, ensuring that behavioral health care is a core part of person-centered care planning.
Additionally, the proposed rule reinforces CMS’ commitment to advancing health equity and driving quality in health coverage. For the first time, CMS proposes establishing a health equity index in the Star Ratings program that would reward excellent care for underserved populations by Medicare Advantage and Medicare Part D plans. The rule also proposes updates to the Medicare Part D medication therapy management (MTM) program to improve access, including a proposed requirement that plans include all 10 core chronic diseases identified by CMS — including HIV/AIDS — in their MTM targeting criteria. Plans would also 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 proposed interpreter standards and the requirement that materials be provided in alternate formats and languages. Finally, the proposed rule would balance the emphasis between patient experience, complaints, and access Star Ratings measures and health outcomes Star Ratings measures to more effectively focus both on patient-centric care and on improving clinical outcomes.
In order to implement section 11404 of the Inflation Reduction Act (Pub. L. 117-169), CMS proposes to expand eligibility under the low-income subsidy (LIS) program. Under the IRA provision and proposal, individuals with incomes up to 150% of the federal poverty level and who meet statutory resource requirements will qualify for the full LIS beginning on or after January 1, 2024. This change will provide the full LIS to those who would currently qualify for the partial LIS, improving access to affordable prescription drug coverage and lowering costs. 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.
The proposed rule can be accessed at the Federal Register at https://www.federalregister.gov/public-inspection/current. Comments on the proposed rule are due by February 13, 2023.
View the fact sheet on the proposed rule here.
