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the proposed changes, and of special interest for health IT is CMS’ calling for the adoption and implementation of a newer version of the SCRIPT Standard, as well as the NCPDP Real-Time Prescription Benefit Standard (RTPB).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:
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.
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.
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.
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.
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.
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.