CMS Proposes Changes to Medicare Advantage and Medicare Prescription Drug Plans

 Medicare Advantage (MA) Plans – Part C Enhancing Rules on Internal Coverage Criteria: CMS is proposing to define the meaning of “internal coverage criteria,” establishing policy guardrails to ensure access to benefits, and adding more specific rules about publicly posting internal coverage criteria content on MA organization websites.

Access to Behavioral Health Benefits: CMS proposes to require MA and Cost Plans’ in-network cost sharing for certain categories of mental health and substance use disorder services (collectively called “behavioral health services”) be no greater than cost sharing for those services under Traditional Medicare, beginning in contract year 2026.

Enhancing the Health Equity Analysis: CMS proposes to revise the required metrics for the annual health equity analysis of the use of prior authorization to require the metrics be reported by each item or service, rather than aggregated for all items and services.

Promoting Community-Based Services and Enhancing Transparency of In-Home Service Contractors: CMS proposes to: (1) codify definitions of community-based organizations (CBOs), in-home or at-home supplemental benefit providers and direct furnishing entities; (2) require plans to identify, within the provider directory, which providers and direct furnishing entities meet the proposed definition of a CBO; (3) require plans to identify in-home or at-home supplemental benefit providers and direct furnishing entities, including those that provide a hybrid of services (both in-home or at-home, and in-office services), either through a subset list within the provider directory or through a separate list comprising in-home or at-home supplemental benefit providers and direct furnishing entities; and (4) clarify existing policy by stating that all direct furnishing entities must be included within the provider directory.

Improving Experiences for Dually Eligible Enrollees: CMS  proposes to establish new federal requirements for dual eligible special needs plans (D-SNPs) that are applicable integrated plans (AIPs) to 1) have integrated member ID cards that serve as the ID cards for both the Medicare and Medicaid plans in which an enrollee is enrolled, and 2) conduct an integrated health risk assessment (HRA) for Medicare and Medicaid, rather than separate HRAs for each program. Also proposed are timeframes for special needs plans to conduct HRAs and individualized care plans (ICPs) and prioritize the involvement of the enrollee or the enrollee’s representative, as applicable, in the development of the ICPs.

Format Provider Directories for Medicare Plan Finder: CMS is proposing to require MA provider directory data be submitted for use to populate Medicare Plan Finder (MPF) in a format, manner, and timeframe determined by CMS. In addition, we are proposing to require MA organization to attest that this information is accurate and consistent with data submitted to comply with CMS’s MA network adequacy requirements.

Administration of Supplemental Benefits Coverage through Debit Cards: CMS is proposing to codify existing guidance and new protections regarding the administration of supplemental benefits, including the proper administration of plan debit cards. Also proposed are additional guardrails to increase transparency and access around covered benefits that are administered through plan debit cards, as well as a marketing prohibition.

Medicare Prescription Drug Plan (Part D) Changes to Vaccine and Insulin Cost Sharing: CMS proposes no cost sharing for an adult vaccine recommended by the Advisory Committee on Immunization Practices (ACIP) covered under Part D. Additionally, Medicare Part D deductible shall not apply to covered insulin products, and the Part D cost-sharing amount for a one-month supply of each covered insulin product must not exceed the proposed “covered insulin product applicable cost-sharing amount.”

Medicare Prescription Plan Payment Program: CMS proposes to require Part D sponsors to provide all Part D enrollees the option to pay their out-of-pocket (OOP) prescription drug costs in monthly amounts over the course of the plan year, instead of paying OOP costs at the point of sale.

Part D Coverage of Anti-Obesity Medications (AOM): CMS proposes to expand coverage of AOMs to Part D enrollees and Medicaid enrollees (in states that do not already provide coverage of AOMs for weight loss) with obesity who do not already have another condition for which the AOM’s prescribed use is a medically accepted indication that is coverable under current policy.

Promoting Transparency for Pharmacies and Protecting Beneficiaries from Disruptions: CMS proposes to require Part D sponsors to notify network pharmacies which plans the pharmacies will be in-network for in a given plan year by October 1 of the year prior to that plan year.

Marketing Expand Agent and Broker Requirements Regarding Medicare Savings

Programs, Extra Help, and Medigap: CMS proposes to add requirements for agents and brokers to discuss the availability of low-income supports including the Part D Low-Income Subsidy and Medicare Savings Programs, as well as Federal Medigap guaranteed issue rights and the practical implications of switching from Medicare Advantage to Traditional Medicare. In addition, require that agents pause to address remaining questions the beneficiary may have related to enrollment in a plan prior to moving forward with an enrollment.

Enhancing Review of Marketing & Communications: CMS proposes to broaden the marketing definition in order to expand CMS oversight of MA and Part D communications materials and activities and strengthen beneficiary protections against misleading and confusing advertising tactics. Broadening the definition of marketing would expand the scope of the materials that must be prospectively submitted to CMS for review, which would allow CMS to better ensure that MA organizations, Part D sponsors, and their downstream entities are not providing misleading, inaccurate, or confusing information to current or potential enrollees, or engaging in activities that could misrepresent the MA organization or Part D sponsor.

Public comments on the proposed rule are due on January 27, 2025. The Alliance is further reviewing the proposed rule and will submit comments as appropriate.