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CMS Offers Tighter Marketing and Network Adequacy for Medicare Advantage

Medicare Advantage Plans may soon see stricter marketing rules and more control over how Medicare income is spent if Medicare and Medicaid Services finalize a new proposed rule.

Medicare Part D plans may be facing changes in how they can use the savings from pharmacy pricing arrangements. CMS published by The Medicare Advantage Regulations and Part D of 2023 on Thursday.

In addition, the draft regulation includes several proposals to improve Medicare benefits for beneficiaries who are dual eligible for Medicare and Medicaid.

CMS wants to strengthen its oversight of third-party marketing organizations to weed out what it describes as deceptive marketing tactics in Medicare Advantage and Medicare Part D. The agency is proposing to return the requirement that plans include multilingual boxes in certain materials informing clients about free services. language and translation services. This rule will also codify student ID card standards, requirements for waiving restricted access to preferred cost-sharing pharmacies, and website requirements.

In addition, the CMS wants to strengthen its oversight of the plans, providing additional reasons for refusing to conclude a new contract or expand the service area based on previous work of telecom operators. CMS suggests adding a star rating of 2.5 or below, filing for bankruptcy or bankruptcy, and exceeding the CMS’s threshold for compliance actions as a reason to reject filings.

Network adequacy standards will also be improved. The CMS proposes requiring plan applicants to demonstrate that they have an adequate selection of contracted suppliers.

Part D plans may have agreements with out-of-spec pharmacies to pay less for drugs sold at those pharmacies. The CMS requires these insurers to use all the savings from these deals for the agreed drug price. According to the CMS, this will help the beneficiaries to participate in the savings. news bulletin… The agency also proposes to revise the negotiated price as the minimum allowable payment to the pharmacy from January 1, 2023.

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“We are committed to providing older Americans and people with disabilities who are served by Medicare with access to quality, affordable health care, including prescription drugs and treatments,” CMS administrator Chiquita Brooks-LaSure said in a statement. news release… “The actions proposed today follow our guiding principles by improving health equity and expanding access to prescription drugs.”

The agency wants to make the plan more accountable for spending Medicare revenues. CMS proposes to re-establish next year the medical loss rate reporting requirements that were used from 2014 to 2017. Currently, Medicare Advantage and Part D carriers must report the percentage of income they spend on patient care and quality improvement and the amount they must pay. back to the CMS, unless they spend at least 85% of their money on these activities. The CMS also wants Medicare Advantage and Part D organizations to provide the basic cost and income information needed to calculate and verify the percentage of medical losses and the amount of remittances.

CMS also suggests requiring Medicare Advantage plans to report the amount they are spending on additional benefits that are not available through traditional Medicare.

In addition, CMS offers several suggestions to improve the experience of dual Medicare Advantage members, starting with requiring all special needs plans to have the dual right to create and maintain at least one member advisory committee. Insurers should consult with health equity advisory committees, CMS said.

The agency also proposes to include questions on access to housing, food security and transport in health risk assessments for plans with special needs.

The agency wants to codify the system that states must require certain special needs plans with dual rights to integrate their Medicare and Medicaid materials for members so that they can more easily understand their benefits.

CMS proposes to create an additional avenue for states with integrated health care programs to require Medicare Advantage plans to contract that only have dual eligible special needs plans. The agency expects this to help identify differences between dual-eligible special needs plans and other Medicare Advantage plans, and stimulate improvements for dual-eligible recipients.

Finally, the CMS wants to indicate that Medicare Advantage plans’ cash caps should be calculated based on the accumulation of all Medicare cost-sharing in plan benefits, regardless of whether Medicaid, insurer, or other payer covered the costs. CMS estimates this will save government Medicaid agencies $ 2 billion and increase payments to providers serving dual-eligible individuals by $ 8 billion over 10 years.

Comments on the proposed rule must be submitted by March 7th.


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