CMS Rolls Out Part D/MA Final Rule  

Federal officials this week announced the rollout of a Final Rule for Medicare Part D prescription drug plans and the rapidly expanding Medicare Advantage (MA) program for the 2025 contract year, heralding what they described as guidance to “build on existing CMS (Centers for Medicare & Medicaid Services) policies to promote competition, increase access to care, including important behavioral health services, and protect individuals from inappropriate marketing and prior authorization.”

“Competition within Medicare Advantage and Medicare Part D will provide consumers with meaningful choices among plans so they can select one that best meets their individual needs. Additional consumer protections will help people make the right decisions and get the coverage they want without hassles,” U.S. Department of Health and Human Services (HHS) Secretary Xavier Becerra said in a statement. “We know that increased competition is good for the marketplace. That’s why the Biden-Harris Administration continues to increase competition in healthcare and lower costs, helping build on steps the Administration has already taken, as well as identify opportunities to further spur innovation.”

“CMS is continuing its commitment to ensuring that Medicare Advantage and Part D prescription drug plans remain strong, stable, and affordable for people with Medicare,” CMS Administrator Chiquita Brooks-LaSure added. “This final rule builds on Biden-Harris Administration efforts to strengthen consumer protections so that people with Medicare can more easily choose the Medicare coverage options that are right for them.”

Using particularly strong language, the federal agencies issued a press release saying they were taking “unprecedented steps” to address what they described as “predatory marketing” enmeshed with the Medicare Advantage and Part D programs, establishing a set amount a plan can compensate an agent or broker, in an effort they said would protect enrollees and prospective enrollees from anti-competitive steering. In addition, CMS said it is codifying a provision prohibiting personal beneficiary data collected by Third-Party Marketing Organizations (TPMOs), for marketing or enrolling a person into a Medicare Advantage or Part D plan, from being shared with another TPMO unless prior express written consent is given by the enrollee.

CMS is also requiring that MA plans include an “expert in health equity” on their utilization management committees, and for the committees to conduct an annual health equity analysis of the plans’ prior authorization policies and procedures, in order to “identify any disproportionate delay or denial of access to needed care for enrollees who have a disability or limited income and resources.”

The Final Rule also seeks to promote access to behavioral health providers and services for people with MA plans to help ensure they can receive essential treatments for mental health and substance use disorders, expanding access to network adequacy evaluation requirements to a new outpatient behavioral health specialty type. That includes, officials noted, marriage and family therapists and mental health counselors who are now able to bill under Original Medicare, as well as addiction medicine clinicians, opioid treatment providers, and other behavioral health practitioners providing psychotherapy or medication for substance use disorder.

“Additionally, the rule finalizes new guardrails for certain types of supplemental benefits, available only to chronically ill enrollees, to ensure that these supplemental benefits offered by a Medicare Advantage plan meet the health needs of people with Medicare by being supported by evidence,” the press release read. “The rule also requires Medicare Advantage plans to send a mid-year, personalized communication to their enrollees about accessing unused supplemental benefits. These actions ensure that the large federal investment of over $65 billion per year of taxpayer dollars in supplemental benefits will meet enrollee needs and will not be used just for marketing.”

“In my travels around the country, I always hear from Medicare enrollees that Medicare can be confusing, and access to accurate, unbiased, actionable information is vital – whether it’s about enrollment or how to access services,” said Dr. Meena Seshamani, CMS Deputy Administrator and Director of the Center for Medicare. “This final rule builds on the bold actions we took last year to improve access to care and address predatory marketing, strengthening the Medicare program and improving the lives of the people we serve.”

An estimated 33.4 Americans are currently enrolled in MA plans, with that figure recently eclipsing the halfway mark of all Medicare enrollees. The Biden Administration announced earlier this year that it was poised to begin collecting feedback regarding proposed sweeping changes to the MA marketplace.

The Request for Information (RFI) issued on Jan. 25 came after officials last month announced an intent to promote competition in healthcare, including “increasing transparency” in the MA insurance market and strengthening MA programmatic data.

In a CMS-HHS joint press release issued at that time, officials noted that the government is expected to pay MA health insurance companies over $7 trillion over the next decade. The information solicited by the RFI will “support efforts for MA plans to best meet the needs of people with Medicare, for people with Medicare to have timely access to care, to ensure that MA plans appropriately use taxpayer funds, and for the market to have healthy competition,” the release read.

Overall, MA enrollment varies widely from location to location. In pockets of southern California, central Alabama, and western New York and Pennsylvania, nearly every county shows MA market penetration at more than 60 percent. Yet in entire states in the Rockies and upper Midwest, such as the Dakotas, Wyoming, and Nebraska, nearly the entire state is at less than 20 percent.

Comments for the RFI are due by May 29. The MA data RFI can be accessed on the Federal Register’s webpage at https://www.federalregister.gov/public-inspection/2024-01832/request-for-information-medicare-advantage-data.