Proposed Rule Would Lower Part D Drug Costs, Increase MA Plan Oversight & More

pile of red and blue pills on top of Rx paper

Earlier this month, the Centers for Medicare and Medicaid Services issued a proposed rule with needed and welcomed changes for Medicare Advantage and Part D plans. Some of the changes include: lowering Part D out-of-pocket costs for beneficiaries starting January 1, 2023, increasing marketing oversight and holding plans accountable for misinformation – including information from their third party marketing organizations, ensuring beneficiary access to care during emergencies, giving CMS the authority to deny plan expansions based on past plan ratings of 2.5 stars or less, ensuring plans have adequate pharmacy and provider networks, simplifying the appeals and grievances process, requiring Special Needs Plans to screen for the social determinants of health in their Health Risk Assessments, and requiring greater transparency in Medical Loss Ration (MLR) reporting, which is generally the ratio representing the percentage of revenue used for patient care versus that used for other items such as administrative expenses or profit.

To read a full summary of changes with more details, see CMS’ fact sheet: CY 2023 Medicare Advantage and Part D Proposed Rule (CMS-4192-P).

While we are thrilled to see these changes, we also see that these proposed rules still fall short of providing needed consumer protections for MA plan enrollees and the Medicare program. Below are list of shortcomings as summarized by our partners, Center for Medicare Advocacy, in their recent article on CMS’s Proposed 2023 Rule for Medicare Advantage and Part D Plans.

Areas for CMS to take further action:

  • Oversight of MA Coverage and Care Denials, including restricting rampant use of prior authorization (PA) (the proposed rule only contains a request for information concerning PA for hospital transfers to post-acute care settings during a public health emergency – we assert that the problems created by PA are much more widespread and must be addressed more broadly)
  • Revising MA flexibilities re: uniformity standards, meaningful differences that make it more difficult for beneficiaries to make informed decisions
  • MA network adequacy – as noted above, the proposal re: tighter restrictions for new entrants is welcome, but the overall thresholds were weakened in recent years
  • No new rights for beneficiaries re: Special Enrollment Periods (e.g. for mid-year provider terminations by plans)
  • No rescission of allowance of MA plans to apply step-therapy to Part B drugs
  • No reinstating of reporting requirements re: appeals
  • No expansion of services that limit cost-sharing to traditional Medicare levels
  • Marketing Communications Guidelines – while the proposed changes noted above are both welcome and necessary, CMS should reverse the significant changes to the guidelines that have weakened protections in recent years, and add new requirements; for example, as noted above, CMS should:
    • Rescind rules weakening marketing v. educational events
    • Impose requirements re: MA descriptions of supplemental benefits for the chronically-ill (SSBCI)

We applaud CMS for addressing so many important areas, especially in regard to increased oversight of Medicare Advantage plans. And we encourage CMS to go further in making the changes necessary for greater consumer protections (especially for MA plan enrollees) and strengthening Original Medicare.

Karen Joy Fletcher

Our blogger Karen Joy Fletcher is CHA’s Communications Director. With a Masters in Public Health from UC Berkeley, she is the online “public face” of the organization, provides technical expertise, writing and research on Medicare and other health care issues. She is responsible for digital content creation, management of CHA’s editorial calendar, and managing all aspects of CHA’s social media presence. She loves being a “communicator” and enjoys networking and collaborating with the passionate people and agencies in the health advocacy field. See her current articles.