November 17, 2017

What CMS has in store for Medicare Advantage and Part D plans in 2019

Daily Briefing

    CMS on Thursday unveiled a proposed rule for Medicare Advantage (MA) and Part D plans for the 2019 coverage year.

    MA updates

    CMS proposed eliminating requirements that insurers show their plans are "substantially different" from others they offer in the same county in terms of benefits, cost-sharing, and premiums. CMS said eliminating the requirement would "improve competition, innovation, available benefit offerings, and provide beneficiaries with affordable plans that are tailored for their unique health care needs and financial situation."

    CMS also proposed limiting automatic MA plan enrollment of new dually eligible beneficiaries who were previously in affiliated Medicaid managed care plans. The proposed rule also would expand passive enrollment rules to allow "passive enrollment for full-benefit dually eligible beneficiaries from a non-renewing integrated D-SNP to another comparable plan."

    In addition, CMS proposed revising the way that medical loss ratio calculations treat "fraud reduction activities." Under current law, MA insurers must spend at least 85% of premiums on health care, not including fraud-related activities. According to According to Axios' "Vitals," insurers have sought to have fraud included as a health care expense because doing so could reduce their calculated administrative expenses and increase profits.

    CMS also proposed replacing the current MA disenrollment period that runs from Jan. 1 to Feb. 14, during which beneficiaries can switch from an MA plan to traditional Medicare, with a new open enrollment period that would run from Jan. 1 to March 31 beginning in 2019.

    Part D updates

    CMS also is seeking public comment on how to apply at the point of sale certain Medicare Part D rebates and discounts that are typically negotiated behind the scenes by manufacturers, pharmacists, and insurers. CMS said under the current process discounts are "rarely" passed on to beneficiaries who, as a result, end up "paying a larger share of the actual cost of a drug." According to Axios' "Vitals," applying some of those discounts at the point of sale could potentially reduce beneficiaries' costs.

    CMS also proposed changes that would allow Medicare Part D plan sponsors to establish drug management programs for beneficiaries considered at risk for drug misuse, including opioids, under the Comprehensive Addiction and Recovery Act (CARA).

    In addition, CMS proposed:

    • Allowing enrollees to choose the pharmacy from which they want to purchase their medications;
    • Allowing for midyear changes to prescription drug formularies when a generic becomes available; and
    • Calculating out-of-pocket costs for biosimilars, such as cancer drug Zarxio, in the same way such costs are determined for generics.

    Regulatory burdens

    CMS also proposed several changes intended to reduce regulatory burdens under CMS' Patients Over Paperwork initiative, such as:

    • Allowing MA plans to send more materials to beneficiaries electronically;
    • Eliminating requirements that plans submit accounting information along with their bids; and
    • Streamlining government review and approval processes for communications between plans and their beneficiaries.

    Overall, CMS estimated the proposed changes would save Medicare $195 million annually over five years.

    CMS is accepting comments on the proposals until Jan. 16 (Jane Tribble, Kaiser Health News, 11/16; Diamond, "Pulse," Politico, 11/17; CMS fact sheet, 11/16; Baker, "Vitals," Axios, 11/17).

    Next: Streamline PA processes for provider-administered drugs

    Prior authorization (PA) processes have long been an administrative burden for providers. In recent years, securing PAs has become even more difficult due to increasing requirements and greater variation in health plan benefit structure.

    Join our experts on Thursday, Nov. 30 at 3 pm ET to learn best practices for staffing, process redesign, improving information flow, and working with payers to reduce PA requirements.

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