HHS Finalizes Rule to Strengthen Medicare, Improve Access to Affordable Prescription Drug Coverage, and Hold Private Insurance Companies Accountable for Providing Quality Health Care to America’s Elderly and Disabled

CMS: Thanks to President Biden’s new law to reduce prescription drug costs, the final rule will also improve access to affordable prescription drug coverage for approximately 300,000 low-income people

April 9, 2023 — Last week, the U.S. Department of Health and Human Services (HHS), through the Centers for Medicare & Medicaid Services (CMS), finalized a rule to prioritize people on Medicare and put strong protections in place to make Medicare Advantage (MA) work for them. This final rule will strengthen Medicare Advantage and hold health insurance companies to higher standards for America’s elderly and disabled by cracking down on the deceptive marketing programs of Medicare Advantage plans, Part D plans and their entities in downstream ; remove barriers to care created by complex coverage criteria and utilization management; and expanding access to behavioral health care. The new rule will also promote health equity and implement a key provision of the Cutting Inflation Act – President Biden’s new law to reduce prescription drug costs – which will improve the access to affordable prescription drug coverage for approximately 300,000 low-income people.

The Biden-Harris administration is committed to protecting and strengthening Medicare for the 65 million people on Medicare today and for future generations. Over the past several months, the Department has taken a series of steps to ensure the Medicare Advantage program works for people on Medicare and that private insurance companies are held accountable for providing quality coverage and care. :

• In February, CMS finalized a rule to begin recovering improper payments made to Medicare Advantage plans through audits for the first time since 2007. Recovering those improper payments and returning that money to Medicare trust funds will protect the financial viability of Medicare and enable the program to better serve seniors and people with disabilities, today and tomorrow.
• Last week, CMS finalized policies in the 2024 Medicare Advantage and Part D Rate Announcement to improve payment accuracy and ensure taxpayer dollars are properly protected and well spent.

“At HHS, we prioritize the elderly and people with disabilities,” HHS Secretary Xavier Becerra said. “That’s exactly what we’re doing today. In our latest effort to strengthen Medicare and hold insurance companies accountable, we’re putting in place protections to make Medicare Advantage work for beneficiaries and get the quality care they deserve. We will continue our efforts to realize the President’s vision to strengthen this program for the millions of people on Medicare and for future generations.

“The Biden-Harris administration has made it exceptionally clear that one of its top priorities is to protect and strengthen Medicare,” said CMS Administrator Chiquita Brooks-LaSure. “With this final rule, CMS is implementing new safeguards that make it easier for people with Medicare to access the benefits and services to which they are entitled, while strengthening the Medicare Advantage and Part D programs.”

“People on Medicare deserve access to accurate information when making coverage choices and to be able to get the care they need without undue burden or delay,” said Dr. Meena Seshamani, deputy administrator of CMS and director of the Center for Medicare. “The common-sense policies contained in this rule reinforce our goals of advancing health equity, improving access to care, and supporting high-quality care for the whole person.”

Crack down on deceptive marketing schemes

The final rule includes changes to protect people exploring Medicare Advantage and Part D coverage from confusing and potentially misleading marketing practices. Ads will be prohibited if they fail to mention a specific plan name, or if they use the Medicare name, CMS logo, and federally issued products or information, including the Medicare card, in a misleading manner. In addition, the final rule reinforces accountability for agent and broker activity monitoring plans.

Breaking down the barriers to care created by the complex management of prior authorizations and use

CMS also provides important protections regarding utilization management policies and coverage criteria that ensure Medicare Advantage enrollees receive the same access to medically necessary care they would receive under traditional Medicare. The rule streamlines pre-authorization requirements and reduces disruption to enrollees by requiring that a granted pre-authorization approval remain valid for as long as medically necessary to avoid interruptions in care, by requiring Medicare Advantage plans to review each year utilization management policies and requiring denials of coverage based on medical necessity to be reviewed by medical professionals with relevant expertise before a denial can be issued. These policies complement the proposals in the CMS Proposed Rule for Promoting Interoperability and Improving Prior Authorization Processes (CMS-0057-P).

Expanding Access to Behavioral Health Care

CMS remains committed to emphasizing the essential role that access to behavioral health plays in the care of the whole person. In agreement with CMS Behavioral Health Strategy and the Administration’s strategy to address the national mental health crisis, CMS strengthens the adequacy of the behavioral health network in Medicare Advantage by adding licensed clinical psychologists and clinical social workers to the list of specialties assessed. CMS is also finalizing wait time standards for behavioral health and primary care services and more specific plan notification requirements to patients when these providers are removed from their networks. Additionally, CMS requires 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.

Promoting more equitable care

Additionally, CMS is advancing health equity and improving the quality of health coverage by establishing a Health Equity Index in the Star Ratings program that will reward Medicare Advantage and Medicare Part D plans that provide excellent patient care. underserved populations. Plans will 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 new expanded requirements for providing documentation in d other formats and languages. The final rule balances patient experience/complaint metrics, access metrics, and health outcome metrics in the Star Ratings program to more effectively focus on both patient-centered care and improving clinical outcomes.

Implementation of President Biden’s new prescription drug law

The final rule also implements a key provision of the Reducing Inflation Act that improves access to affordable prescription drug coverage for approximately 300,000 low-income people. As outlined in President Biden’s new prescription drug law, CMS is extending eligibility for the Full Low-Income Subsidy Benefit (also known as “Extra Assistance”) to those whose incomes are up to 150% of federal poverty level and who meet the eligibility criteria. Effective January 1, 2024, this change will provide the full Low Income Subsidy to those who would currently qualify for the Partial Low Income Subsidy. As a result of this change, eligible enrollees will have no deductible, no premium (if enrolled in a “benchmark” plan), and fixed and reduced copayments for certain drugs under Medicare Part D .

See a fact sheet on the final rule.

The final rule can be viewed from the Federal Register at: https://www.federalregister.gov/public-inspection/2023-07115/medicare-program-contract-year-2024-policy-and-technical-changes-to-the-medicare-advantage-program.

Extending the Medicare Advantage value-based insurance design model

Additionally, today CMS is also releasing more information about the extension of the Center for Medicare Advantage (VBID) Value-Based Insurance Design Model from the Center for Medicare and Medicaid Innovation from 2025 to 2030. This extension will introduce changes intended to better meet the health and social needs of patients, advance health equity, and improve the coordination of care for patients with critical illnesses. See the technical sheet, and more information, on the model Web page.
Source: CMS