Recap of the Changes to Medicare Advantage and Medicare Prescription Drug Benefit Proposed Rule

Share this story:

policy summary_circle_largeOur December 20 blog shared highlights from the CMS proposed rule for Advancing Interoperability and Improving Prior Authorization Processes, intended to improve patient and provider access to health information and to streamline processes related to PA for medical items and services. Just one day after releasing those proposed improvements, CMS issued another proposed rule: the Contract Year 2024 Policy and Technical Changes to the Medicare Advantage and Medicare Prescription Drug Benefit Proposed Rule. This proposed rule includes new policies that improve beneficiary protections and increase equity in coverage and access to care, including behavioral health care. It was informed by feedback from the responses to the July 2022 MA request from information that brought in approximately 4,000 responses. 

POCP has carefully analyzed the proposed changes, and of special interest for health IT is CMS’ calling for the adoption and implementation of a newer version of the SCRIPT Standard, as well as the NCPDP Real-Time Prescription Benefit Standard (RTPB). While POCP supports the adoption of the SCRIPT standard which empowers electronic prescribing and electronic prior authorization for medications, we are recommending that CMS, in their final rule, adopt the newest versions of these standards.  Specifically, we recommend adoption of the: 

  • National Council for Prescription Drug Programs (NCPDP) SCRIPT Implementation Guide, Version 2023011, and; 
  • National Council for Prescription Drug Programs (NCPDP), Real-Time Prescription Benefit Standard, Implementation Guide, Version 13 

You can read our full comment letter here but, in this blog, we will summarize the proposed changes and what CMS intends to accomplish with these policy amendments and new requirements. 

Medicare Advantage (MA) and Medicare Part D Improvements 

In response to concerns about the use of prior authorization by MA plans and the effect on beneficiary access to care, the new rule will regulate how MA plans develop and use coverage criteria and utilization management policies. It will also streamline prior authorization requirements and reduce disruption in ongoing care by ensuring authorization remains valid throughout the full course of treatment.  

The proposed rule enacts protections against confusing and potentially misleading marketing to ensure that people enrolled in MA and Part D plans, as well as those shopping for Medicare coverage, have clear and accurate information to make the best coverage choices for their needs. In addition to stronger restrictions on television advertising and sales presentations, agents will be required to inform beneficiaries that they can receive complete information about Medicare options for free by calling 1-800-MEDICARE or visiting www.Medicare.gov 

 Star Ratings Program Improvements  

Proposed changes to the Star Ratings program will help to improve the quality of care for all enrollees using a health equity index (HEI) reward. This index will incentivize MA and Part D plans to improve care for enrollees with certain social risk factors such as dual eligibility, low-income subsidies, and disability. CMS is proposing to better align with other CMS quality programs by reducing the weight of patient experiences/complaints and access measure by half (from four to two) and removing other measure-specific thresholds. 

Improving Access to Care and Health Equity 

The new rule further clarifies the current requirements for MA plans to provide culturally competent care by specifying plans must serve populations: (1) with limited English proficiency; (2) of ethnic, cultural, racial, or religious minority groups; (3) with disabilities; (4) who identify as lesbian, gay, bisexual, or other diverse sexual orientations; (5) who identify as transgender, nonbinary, and other diverse gender identities, or people who were born intersex; (6) who live in rural areas and other areas with high levels of deprivation; and (7) otherwise adversely affected by persistent poverty or inequality. MA plans will be required to develop and maintain digital health education programs to improve the accessibility of telehealth programs, as well as requiring new best practices to improve the usability of provider directories and include providers’ linguistic and cultural capabilities.  

Improving Access to Behavioral Health 

With these proposed changes, CMS is strengthening network adequacy requirements and reaffirming beneficiaries’ rights to access behavioral health programs with their MA plans. The proposed changes to improve access to behavioral health therapies include specific terms for minimum network standards that include behavioral health professionals, codified standards for appointment wait times, and clarified emergency medical services terms. The new rule also requires that MA organizations create care coordination programs that include management and integration of community, social, and behavioral health services.  

Prescription Affordability and Medication Therapy Management  

CMS is proposing to allow Part D sponsors to use tools that provide greater formulary flexibility, including substitution without providing a transition supply of (1) a new interchangeable biological product for its corresponding reference product; (2) a new unbranded biological product for its corresponding brand name biological product; and (3) a new authorized generic for its corresponding brand name equivalent. In addition, Part D sponsors will be required to ensure that Part D medications are appropriately prescribed and provide improved health outcomes as intended, by adhering to Medication Therapy Management program standards.  

POCP commends CMS in its efforts to improve healthcare for individuals who rely on coverage from Medicare Part C, Part D, and PACE, by calling for the adoption of the NCPDP SCRIPT and RTPB Standards. We support many of the changes as proposed in this rule. Our full response is available in our comment letter submitted on January 27, 2023. 

If you need help digging into this or any of the other recent NPRMs and understanding how these proposed rules, once finalized, could impact your organizations, reach out to me at kim.boyd@pocp.com to schedule a chat. Learn more about our Interoperability Outlook subscription by visiting our website or reach out to Brian Dwyer brian.dwyer@pocp.com to schedule a demonstration.