Proposed Rule Strengthens Fairness and Behavioral Health in the Medicare Advantage Program

Proposed Rule Strengthens Fairness and Behavioral Health in the Medicare Advantage Program

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For the first time, the Center for Medicare and Medicaid Services is proposing to establish a health equity index in the Medicare Advantage and Part D Star Ratings program that would reward excellent care for underserved populations.

The proposed rule would also update the Medicare Part D drug therapy management program to require plans to include the top 10 chronic diseases identified by the CMS — including HIV/AIDS — in their drug therapy management targeting criteria. drug therapy.

Plans would also be needed 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 proposed new interpretation standards and requirement that material be provided in other formats and languages, CMS said. .

Finally, the proposed rule would balance the focus between patient experience, complaints, access star rating metrics, and health outcomes.

The proposed rule implements provisions of the Cut Inflation Act to make prescription drugs more affordable for about 300,000 low-income people. CMS is proposing to expand eligibility for the grant program to low-income people.

Individuals whose income does not exceed 150% of the federal poverty level and who meet the statutory resource requirements will be eligible for the Full Low-Income Subsidy beginning January 1, 2024. Eligible enrollees will only have no deductible, no premiums (if enrolled in a “benchmark” plan) and fixed and reduced co-payments for certain drugs.


The proposed rule is released after CMS received nearly 4,000 comments regarding improvements to the Medicare Advantage program from a July request for information. Comments on the proposed rule are expected by February 13, 2023.

In this rule, CMS is proposing significant changes to strengthen protections for individuals enrolled in or seeking coverage under Medicare Advantage plans or Medicare Part D prescription drug plans, including enhancements to prior authorization, plan coverage and marketing requirements.

The rule proposes policies to streamline prior authorization by requiring that a granted prior authorization approval remain valid for an enrollee’s full treatment, requiring Medicare Advantage plans to annually review policies for managing the use and requiring coverage determinations to be reviewed by professionals with relevant expertise, CMS said. .

These proposed policies complement the proposals in CMS’s recently announced Proposed Rule to Advance Interoperability and Improve Prior Authorization Processes, released earlier this month.

Additionally, the proposed rule is intended to protect people exploring Medicare Advantage and Part D coverage from confusing and potentially misleading marketing. The proliferation of some TV ads generically promoting Medicare Advantage enrollment has been a concern, CMS said.

To address this issue, CMS said it is proposing to ban ads that don’t mention a specific plan name as well as ads that use potentially confusing words and images, or use language or logos of in a way that is misleading, confusing or distorting the plan. .

CMS also offers to codify guidelines protecting people on Medicare or exploring Medicare coverage from deceptive marketing and ensuring they are not forced to enroll in plans that may not meet best to their needs. In addition, CMS proposes to strengthen the role of schemes in monitoring the activity of agents and brokers.


CMS said it remains committed to highlighting the invaluable role that access to behavioral health plays in the whole person care.

Consistent with CMS’s Behavioral Health Strategy and the administration’s strategy for addressing the national mental health crisis, CMS is proposing to strengthen the adequacy of the behavioral health network by adding clinical psychologists, clinical social workers approved and prescribers of drugs for opioid use disorders to the list of specialties assessed.

CMS is also proposing new minimum wait time standards for behavioral health and primary care services and more specific plan notification requirements for patients when these providers are removed from their networks.

Finally, CMS proposes to require that most types of Medicare Advantage plans include behavioral health services in care coordination programs, ensuring that behavioral health care is at the heart of person-centered care planning.


“CMS today released a proposed rule that takes significant steps to hold Medicare Advantage plans accountable for providing high-quality coverage and care to enrollees,” said CMS Administrator Chiquita Brooks. -LaSure. “The rule also strengthens Medicare prescription drug coverage and implements an important provision of the Cut Inflation Act to help more people on Medicare who have modest incomes pay for their prescriptions.”

Twitter: @SusanJMorse
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