CMS has put on display a proposed rule that would update Medicare Advantage (MA) and Medicare Part D prescription drug benefit policies for contract year 2021 and 2022. CMS projects that its proposed policies would decrease federal spending by $4.4 billion over 10 years, primarily as a result of a proposal to remove outliers prior to calculating Star Rating system cut points. Other major provisions of the proposed rule include the following:
- CMS proposes to implement several legislative provisions intended to address the opioid epidemic, including expanded beneficiary education requirements and mandatory drug management programs for beneficiaries at-risk for misuse or abuse of frequently abused drugs.
- The proposed rule would codify a statutory provision allowing Medicare-eligible individuals with end-stage renal disease (ESRD) to enroll in MA plans. Effective January 1, 2021, organ acquisitions for kidney transplants for MA beneficiaries will be covered under the Medicare fee-for-service program, and such costs will be excluded from MA benchmarks.
- CMS proposes to strengthen MA plan network adequacy rules, including new policies intended to improve access to providers in rural areas and encourage the use of telehealth providers in contracted networks.
- Part D plan sponsors would be allowed to establish two specialty tiers, instead of the single specialty tier currently permitted. In such cases, one tier must be a "preferred" tier that offers lower cost sharing. CMS believes the additional tier would allow Part D plan sponsors to negotiate additional rebates from manufacturers, but it is also soliciting comment on whether placement on the preferred specialty tier should be limited to generics and biosimilars whose cost exceeds the specialty threshold established by CMS.
- Part D plan sponsors would be required to make available to beneficiaries, through a web portal or mobile app, a real-time benefit tool (RTBT) that provides accurate, timely, and clinically appropriate patient-specific real-time formulary and benefit information (including cost-sharing amount, formulary alternatives and utilization management requirements). While this would generally parallel the RTBT that Part D plan sponsors are required to make available to prescribers beginning January 1, 2021, CMS is considering numerous issues, including P&T committee determination of which formulary alternatives can be omitted and prohibition on outputs "that are intended to promote choices based upon the commercial interests of the part D sponsor rather than the beneficiary's best interests, or the promotion of medications or refills based on the rebates that would be received." CMS is also considering allowing Part D plan sponsors to make available rewards and incentives for beneficiaries using the RTBT, including gift cards. CMS proposes an effective date of January 1, 2022, but solicits comments on whether January 1, 2021 is a feasible effective date.
- CMS proposes to make a series of changes to its Medical Loss Ratio calculations.
Comments on the proposed rule will be accepted until April 6, 2020.
This article is presented for informational purposes only and is not intended to constitute legal advice.