Proposed rule strengthens equity and behavioral health in the Medicare Advantage program

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For the first time, the Centers for Medicare & Medicaid Services is proposing to establish a health equity index in the Medicare Advantage program and Part D Star Ratings that would reward excellent care for underserved populations. the proposed rule it would also update the Medicare Part D drug therapy management program to require plans to include the top 10 chronic conditions identified by CMS including HIV/AIDS in its criteria for guiding the management of drug therapy.

Plans would also be required 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 newly proposed interpretation standards and the requirement that materials be provided in alternate formats and languages, CMS said. .

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

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

Individuals with income up to 150% of the federal poverty level and who meet legal resource requirements will qualify for the full low-income subsidy beginning January 1, 2024. Eligible enrollees will have no deductible or premium (if are enrolled in a “benchmark” plan) and fixed, reduced copays for certain drugs.


the proposed rule is published after CMS received nearly 4,000 comments on improving the Medicare Advantage program from a July Request for Information. Comments on the proposed rule must be submitted by February 13, 2023.

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

The rule proposes policies to simplify prior authorization by requiring that a prior authorization approval granted remain valid for an enrollee’s entire course of treatment, by requiring Medicare Advantage plans to review utilization management policies annually, and by requiring that coverage determinations be reviewed by professionals with relevant experience, CMS said. .

These proposed policies complement the proposals in CMS’ recently announced Promoting Interoperability and Improving Prior Authorization Processes Proposed rule published earlier this month.

In addition, the proposed rule is focused on protecting people exploring Medicare Advantage and Part D coverage from confusing and potentially misleading marketing. The proliferation of certain television advertisements generically promoting Medicare Advantage enrollment has been a matter of concern, CMS said.

To address this, CMS said it is proposing to ban ads that do not mention a specific plan name, as well as ads that use words and images that could be misleading, or that use language or logos in a misleading or confusing way, or that misrepresent the plan.

CMS is also proposing to codify the guidance to protect people with Medicare or explore Medicare coverage from deceptive marketing and ensure they are not pressured to enroll in plans that do not best meet their needs. In addition, CMS proposes to strengthen the role of plans in monitoring the activity of agents and brokers.


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

Consistent with CMS’s behavioral health strategy and the administration’s strategy to address the national mental health crisis, CMS proposes to strengthen the adequacy of the behavioral health network by adding clinical psychologists, licensed clinical social workers, and medication prescribers for the opioid use disorder to the list of evaluated specialties.

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

CMS is also proposing to require that most types of Medicare Advantage plans include behavioral health services in care coordination programs, to ensure that behavioral health care is a central part of focused care planning. in person.


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

Twitter: @SusanJMorse
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