CMS proposes stricter marketing and network adequacy recommendations for Medicare Advantage

CMS proposes stricter marketing and network adequacy recommendations for Medicare Advantage

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If the Centers for Medicare and Medicaid Services finalize a new proposed rule, the Medicare Advantage program will soon see stricter marketing guidelines and more oversight of how Medicare revenue is spent.

The Medicare Part D plan may face changes in how to use the cost savings of the pharmacy pricing arrangement.Content management system Publish 2023 Medical Insurance Advantages and Part D Regulations Thursday.

In addition, the draft regulation also includes several proposals aimed at improving the medical insurance advantages of beneficiaries who are eligible for both medical insurance and medical assistance.

CMS hopes to strengthen the supervision of third-party marketing organizations to eliminate what it describes as deceptive marketing strategies in Medicare Advantage and Medicare Part D. Language and translation services. The rule will also codify participant ID card standards, disclaimer requirements and website requirements that restrict access to preferred cost-sharing pharmacies.

In addition, CMS hopes to strengthen plan oversight by proposing other reasons for rejection of new contracts or service area expansion based on the operator’s previous performance. CMS recommends adding a star rating of 2.5 or lower, bankruptcy or bankruptcy filing, and exceeding the CMS compliance action threshold as the basis for rejection of the application.

Network adequacy standards will also be improved. CMS recommends requiring program applicants to indicate that they will have sufficient contract provider options.

Part D plans can reach agreements with pharmacies that do not meet certain criteria to reduce the cost of dispensing medicines at these pharmacies. CMS hopes to require these insurance companies to use all the savings from these transactions to negotiate prices for drugs.According to CMS, this will help beneficiaries share savings Fact SheetThe agency also proposes to redefine the negotiated price as the minimum acceptable payment for pharmacies, starting on January 1, 2023.

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CMS administrator Chiquita Brooks-LaSure said in a statement: “We are committed to ensuring that American seniors and people with disabilities who receive Medicare services have access to high-quality, affordable health care, including prescription drugs and therapies.” Press Releases“The actions proposed today follow our guiding principles by improving health equity and increasing access to prescription drugs.”

The agency hopes to increase the accountability of the plan for how they spend their health insurance income. CMS proposes to restore the medical loss rate reporting requirements used from 2014 to 2017 next year. Medicare Advantage and Part D operators must currently report the percentage of income they spend on patient care and quality improvement, and the amount that must be paid. If they do not use at least 85% of the funds for these activities, they return to CMS. CMS also wants Medicare Advantage and Part D organizations to report basic cost and income information required to calculate and verify the percentage of medical loss rate and the amount of remittance.

CMS also recommends requiring Medicare Advantage plans to report the amount they spend on supplementary benefits that traditional Medicare cannot provide.

In addition, CMS provides a number of suggestions to improve the experience of dual-qualification enrollees in Medicare Advantage. First, all dual-qualification special needs plans are required to establish and maintain at least one enrollee advisory committee. CMS stated that insurance companies should consult an advisory committee on the subject of health equity.

The agency also proposed to include issues related to housing, food safety, and transportation access into the health risk assessment of the special needs plan.

The agency hopes to compile a system for states to require certain dual-eligible special needs programs to integrate their medical insurance and medical assistance materials for registrants so that registrants can more easily understand their benefits.

CMS proposes to create an additional pathway for states with comprehensive care plans to require Medicare Advantage plans to establish contracts with only dual-qualified special needs plans. The agency hopes this will help clarify the differences between the dual eligibility special needs plan and other Medicare Advantage plans, and promote the improvement of dual eligibility beneficiaries.

Finally, CMS wants to specify that the maximum out-of-pocket expense limit of the Medicare Advantage plan should be calculated based on the cumulative calculation of all Medicare cost allocations in the plan’s benefits, regardless of whether Medicare, policyholders or other payers cover expenses. CMS believes that this will save the state’s Medicaid agency $2 billion and increase payments to providers that provide services to dual-qualified beneficiaries by $8 billion within 10 years.

Comments on the proposed rules will expire on March 7.

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