CMS Final Rule Strengthens Medicare Advantage and Part D Transparency

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The Centers for Medicare and Medicaid Services released a final rule on Friday with policies intended to provide greater transparency for Medicare Advantage and Part D plans.

The 2023 Medicare Advantage and Part D Final Rule also advance more affordable health care, CMS said, by reducing out-of-pocket costs for prescription drugs beginning in 2024.

CMS has finalized the policy that requires Part D plans to apply any price concessions they receive from network pharmacies to the negotiated point-of-sale price. This means the recipient can share in the savings, CMS said, because the policy reduces out-of-pocket costs to the recipient and improves price transparency and market competition under the Part D program.

Specifically, CMS is redefining the negotiated price as the base, or lowest possible, payment to a pharmacy, effective January 1, 2024.

Matt Eyles, president and chief executive of AHIP, a trade association for health insurers, said: “As we continue to review the final rule, we are very disappointed that CMS has not withdrawn its proposed require that all possible pharmacy price concessions be included in a Part D plan’s negotiated point-of-sale price. Only pharmacists benefit from this requirement, with seniors and taxpayers paying the price through premiums We appreciate that the CMS is delaying the implementation of the rule to 2024, so that Part D plan sponsors and health insurers will have some time to try to mitigate the impact on senior citizens.”

The rule also clarifies policies to provide beneficiaries enrolled in MA plans with uninterrupted access to necessary services during disasters and emergencies, such as the COVID-19 pandemic.

Another policy revises marketing requirements to strengthen monitoring of third-party organizations against potentially deceptive activity to register members.

To reinforce network adequacy standards, MA applicants must demonstrate that they have a sufficient network of contracted providers to serve beneficiaries before the CMS approves a request for a new contract or expanded.

The final rule adds a star rating of 2.5 or less, bankruptcy or bankruptcy filing, and exceeding designated thresholds for compliance actions as reasons why CMS denies a new app or application extension. service area.

Promote the sustainability of the Medicare program. CMS reinstates Medical Loss Ratio reporting requirements and expands reporting requirements for MA Supplementary Benefits.

“This will improve the transparency of the underlying costs, revenues and incremental benefits of the MA and Part D plans, which will benefit beneficiaries and taxpayers,” CMS said.

CMS reinstates medical loss ratio reporting requirements that were in effect from 2014 to 2017. This requires MA and Part D plans to report the underlying cost and revenue information needed to calculate and verify the MLR percentage and the amount of the payment, if applicable.

In addition, plans will have to report the amounts they spend on various types of additional benefits not available under the original health insurance.

CMS is finalizing a technical amendment to allow CMS to calculate 2023 Part C star ratings for the three measures of the Healthcare Efficiency Data and Information Set (HEDIS) collected through the health outcomes survey: physical activity monitoring; reduce the risk of falling; and bladder control.

Without this technical change, CMS would not be able to calculate the 2023 star rating for these metrics for any MA contract since all contracts are eligible for the Extreme and Uncontrollable Circumstances Adjustment for COVID-19, CMS said.

CMS is also finalizing a series of changes that were established in the March 31, 2020 COVID-19 Interim Final Rule and the September 2, 2020 COVID-19 Interim Final Rule to the 2021 and 2022 Star Ratings to accommodate the discontinuation of data collection posed by the COVID-19 pandemic.

The rule also strengthens coordination between states and CMS to serve people who are both Medicare and Medicaid eligible. This includes codifying a mechanism by which states can require dual-eligibility special needs plans to use integrated materials that make it easier for people with dual eligibility to understand the full scope of their Medicare and Medicaid benefits.

The rule also requires all MA special needs plans to assess certain social risk factors for their enrollees annually, as identifying social needs is a key step in providing person-centered care.

Additionally, CMS closes a loophole for dual-eligible MA enrollees who have high medical expenses that exceed the maximum out-of-pocket limit established by the MA plan. This loophole had resulted in lower payment to providers serving dual-eligible MA enrollees compared to providers serving non-dually eligible MA enrollees.


CMS released the rule the day the Office of Inspector General released an unflattering report on Medicare Advantage pre-authorization denials, compared to Original Medicare. MAOs also withheld payments to providers for certain services that met both Medicare coverage rules and MAO billing rules, according to the report.

No mention of the OIG report was made by CMS, but the agency has made it clear that it wants to know where MA plans are spending their government dollars, both for reasons of transparency and for better supporting social determinants of health.

“Fiscal stewardship is a central tenet of the work we do every day,” said Dr. Meena Seshamani, CMS Deputy Administrator and Director of the Center for Medicare. “As managers responsible for the program, this rule lets us know more about how Medicare money is spent on certain Medicare Advantage benefits, such as housing, food, and transportation assistance, to better understand how we can most effectively support the health and social needs of people on Medicare.”


Dual eligibility for Medicare and Medicaid is a predictor of social risk and poor health outcomes, CMS said. Many people with dual eligibility face challenges such as housing insecurity and homelessness, food insecurity, lack of access to transportation, and low levels of health literacy.

The final rule will help close health disparities by providing integrated, person-centered care that can lead to better health outcomes for enrollees and improve the operational functions of these programs, CMS said.

Twitter: @SusanJMorse
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