Proposed Changes to Strengthen Medicare Advantage and Part D Programs

The Centers for Medicare & Medicaid Services (CMS) has announced a series of proposed changes aimed at enhancing the Medicare Advantage (MA) and Medicare Prescription Drug Benefit Program (Part D). These reforms are in line with a broader economic strategy, often referred to as “Bidenomics,” which emphasizes increasing competition, reducing costs, and ensuring accessible, high-quality healthcare for all Americans.

The proposed regulations intend to help Medicare beneficiaries make more-informed decisions when selecting health coverage plans. A significant aspect of the proposal targets the practices of agents and brokers, ensuring that they prioritize the best interests of enrollees over potential excessive compensation, which can sometimes lead to anti-competitive behavior. This is in direct response to concerns that some MA plans are compensating agents and brokers in ways that may lead to biased enrollment decisions, pushing beneficiaries towards plans that may not fully meet their healthcare needs.

Moreover, the proposals aim to enforce “guardrails” around the compensation for agents and brokers to further protect people with Medicare. CMS is also proposing standardization of plan compensation for agents and brokers to encourage a competitive and fair marketplace.

Another focal point of the proposed rule is improving behavioral healthcare access. CMS plans to add a new facility type to the MA network adequacy requirements, which will include marriage and family therapists, mental health counselors, addiction medicine clinicians, and opioid treatment providers. This expansion aims to address the growing need for mental health and substance use disorder treatment services.

Additionally, the proposed rule seeks to ensure that the supplemental benefits offered by 99 percent of MA plans are meaningful, and not just attractive add-ons. CMS is considering requirements for MA plans to issue mid-year notifications to enrollees about unused supplemental benefits to increase utilization. Furthermore, CMS wants to establish evidence-based requirements for benefits offered as special supplemental benefits for the chronically ill (SSBCI), and improve marketing transparency for these benefits.

In an effort to promote health equity, CMS is proposing to mandate that MA plans have an expert in health equity on their utilization management committees. These committees would be tasked with conducting annual health equity analyses of prior authorization policies, focusing on their impact on underserved enrollees. The findings would need to be publicly posted to enhance transparency into how prior authorization affects these populations.

CMS is also proposing measures to streamline enrollment for individuals eligible for both Medicare and Medicaid, which could provide better integrated care options. Additionally, in a move to bolster competition in the prescription drug market, the proposed rule includes providing more flexibility for Part D plans to substitute lower-cost biosimilar biological products for their reference products, offering more timely access to these alternatives.

The public will have a 60-day period to comment on the notice of proposed rulemaking. All comments must be submitted by Jan. 5, 2024, to one of the addresses listed in the Federal Register. The full text of the proposed rule is accessible on the Federal Register’s website.

By focusing on competition, transparency, and access, the apparent aim is to ensure that Medicare Advantage and Part D serve the best interests of American seniors and individuals with disabilities who rely on these programs for their healthcare needs.