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Dec 14 [press release] -- Today, the U.S. Department of Health and Human Services (HHS), through the Centers for Medicare & Medicaid Services (CMS), proposed a rule to strengthen Medicare Advantage and Medicare Part D prescription drug coverage for the tens of millions of people who rely on the programs for health care coverage. The proposed rule improves protections for people with Medicare, expands access to behavioral health care, and promotes equity in coverage. The proposed rule also implements a key provision of the Inflation Reduction Act to make prescriptions drugs more affordable for approximately 300,000 low-income individuals who will benefit in 2024. . . .

A July 2022 Request for Information on Medicare Advantage drew almost 4,000 comments regarding improvements to the program. We thank stakeholders for their thoughtful feedback, and the policies in this proposed rule are informed by the feedback received.

In this rule, CMS proposes significant changes to strengthen protections for people enrolled in or seeking coverage from Medicare Advantage plans or Medicare Part D prescription drug plans, including through improvements to prior authorization, coverage guidelines, and plan marketing requirements. The rule proposes clarifications and revisions to regulations governing when and how Medicare Advantage plans develop and use coverage criteria and utilization management policies to ensure Medicare Advantage enrollees receive the same access to medically necessary care they would receive in Traditional Medicare. The rule also proposes policies to streamline prior authorization requirements and reduce disruption for enrollees. It does this by requiring that a granted prior authorization approval remain valid for an enrollee’s full course of treatment, requiring Medicare Advantage plans to annually review utilization management policies, and requiring coverage determinations be reviewed by professionals with relevant expertise. These proposed policies complement proposals in CMS’ recently announced Advancing Interoperability and Improving Prior Authorization Processes Proposed Rule (CMS-0057-P).

Additionally, the proposed rule focuses on protecting people exploring Medicare Advantage and Part D coverage from confusing and potentially misleading marketing while also ensuring access to accurate and necessary information to make coverage choices. The proliferation of certain television advertisements generically promoting Medicare Advantage enrollment has been a topic of concern. To address this, CMS proposes to prohibit ads that do not mention a specific plan name as well as ads that use words and imagery that may be confusing, or use language or logos in a way that is misleading, confusing, or misrepresents the plan. CMS also proposes to codify guidance protecting people with Medicare or exploring Medicare coverage from misleading marketing and ensure they are not pressured into enrolling into plans that may not best meet their needs. Further, CMS is proposing to strengthen the role of plans in monitoring agent and broker activity. . . .

CMS remains committed to emphasizing the invaluable role that access to behavioral health plays in whole person care. In line with CMS’ Behavioral Health Strategy and the Administration’s strategy to address the national mental health crisis, CMS proposes to strengthen behavioral health network adequacy by adding clinical psychologists, licensed clinical social workers, and prescribers of medication for opioid use disorder to the list of evaluated specialties. CMS also proposes new minimum wait time standards for behavioral health and primary care services and more specific notice requirements from plans to patients when these providers are dropped from their networks. Finally, CMS proposes to require most types of Medicare Advantage plans include behavioral health service in care coordination programs, ensuring that behavioral health care is a core part of person-centered care planning.

Additionally, the proposed rule reinforces CMS’ commitment to advancing health equity and driving quality in health coverage. For the first time, CMS proposes establishing a health equity index in the Star Ratings program that would reward excellent care for underserved populations by Medicare Advantage and Medicare Part D plans. The rule also proposes updates to the Medicare Part D medication therapy management (MTM) program to improve access, including a proposed requirement that plans include all 10 core chronic diseases identified by CMS — including HIV/AIDS — in their MTM targeting criteria. Plans would also be required to provide culturally competent care to an expanded list of populations and to improve equitable access to care for those with limited English proficiency, through newly proposed interpreter standards and the requirement that materials be provided in alternate formats and languages. Finally, the proposed rule would balance the emphasis between patient experience, complaints, and access Star Ratings measures and health outcomes Star Ratings measures to more effectively focus both on patient-centric care and on improving clinical outcomes.

In order to implement section 11404 of the Inflation Reduction Act (Pub. L. 117-169), CMS proposes to expand eligibility under the low-income subsidy (LIS) program. Under the IRA provision and proposal, individuals with incomes up to 150% of the federal poverty level and who meet statutory resource requirements will qualify for the full LIS beginning on or after January 1, 2024. This change will provide the full LIS to those who would currently qualify for the partial LIS, improving access to affordable prescription drug coverage and lowering costs. As a result of this change, eligible enrollees will have no deductible, no premiums (if enrolled in a “benchmark” plan), and fixed, lowered copayments for certain medications.

The proposed rule can be accessed at the Federal Register at https://www.federalregister.gov/d/2022-26956. Comments on the proposed rule are due by February 13, 2023.

View the fact sheet on the proposed rule here https://www.cms.gov/newsroom/fact-sheets/contract-year-2024-policy-and-technical-changes-medicare-advantage-and-medicare-prescription-drug

Press release: https://www.cms.gov/newsroom/press-releases/hhs-proposes-rule-strengthen-beneficiary-protections-improve-access-behavioral-health-care-and

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