Decoding Medicare's Proposed Rule: Insights for Health IT Stakeholders

Yearly adjustments in healthcare policies are the norm, with some years marking more notable changes. Among these, the Centers for Medicare & Medicaid Services (CMS) consistently refines policies governing Medicare Advantage (Part C) and Medicare Prescription Drug Benefit (Part D) programs. Rooted in the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, these programs evolve in response to healthcare needs, industry shifts, legislative updates, and technological advancements.

Recent CMS proposals for the CY2024 and CY2025 Policy and Technical Changes have caught the attention of a variety of healthcare stakeholders. The initial CY2024 Proposed rule, issued in December 2022, raised expectations for the adoption of key standards like the NCPDP SCRIPT and Real-Time Prescription Benefit (RTPB) Standards. However, subsequent developments in the final rule released in April 2023 altered these provisions, postponing their implementation.

The CY2025 Policy and Technical Changes NPRM, released on November 15, 2023, addresses these postponed elements, aiming to incorporate an updated version of the NCPDP SCRIPT Standard for ePrescribing and ePrior Authorization, alongside naming the NCPDP Real-Time Prescription Standard v13 for prescriber/provider-facing real-time prescription benefit (RTPB). Additionally, it highlights the necessity of an updated version of the NCPDP Formulary and Benefit standard and medication reconciliation.

The proposed updates signify a shift toward utilizing the updated NCPDP SCRIPT version, enabling enhancements in e-prescribing, ePA, and medication history. Key provisions involve retiring older standards and setting deadlines for the exclusive use of newer versions—such as the requirement for NCPDP SCRIPT standard version 2023011 starting January 1, 2027. You can find the NCPDP standards matrix here for more information on particular implementation guides. As stakeholders contemplate the implications of these proposed changes, a crucial call to action emerges… engage in the policymaking process by submitting feedback before the January 5, 2024, deadline. This engagement ensures your voice is heard and considered in shaping these regulatory changes.

Understanding the nuanced impact on an organization's strategic and interoperability roadmap is essential. At Point-of-Care Partners (POCP), we specialize in understanding emerging healthcare technology and standards. To delve deeper into how these proposed rules might specifically affect your organization, feel free to reach out to us at kim.boyd@pocp.com. We're here to collaborate, advocate, and guide you through the intricacies of these proposed changes.

In a landscape as dynamic as healthcare, staying informed and actively engaging in the evolution of policy is pivotal. As we navigate these proposed changes together, our commitment remains steadfast: empowering organizations to leverage technology, standards and process changes for a better, smarter healthcare future.