CMS Proposes Rule That Would Impact Drug Coverage, Prior Authorization | Healthcare Innovation

The Centers for Medicare & Medicaid Services (CMS) has issued a proposed rule to strengthen Medicare Advantage and Medicare Part D prescription drug coverage and prior authorization rules. The rule also proposes changes focused on misleading marketing, behavioral health and health equity.

“We are taking feedback from thousands of Americans and turning it into concrete action to strengthen Medicare for the millions of Americans who rely on it,” said HHS Secretary Xavier Becerra, in a statement. “From streamlining prior authorization to cracking down on misleading marketing, we are committed to ensuring that everyone can have peace of mind and get the healthcare they need.”

The rule proposes clarifications and revisions to regulations governing when and how Medicare Advantage plans develop and use coverage criteria and utilization management policies to ensure Medicare Advantage enrollees receive the same access to medically necessary care they would receive in Traditional Medicare.

The rule also proposes policies to streamline prior authorization requirements and reduce disruption for enrollees. It does this by requiring that a granted prior authorization approval remain valid for an enrollee’s full course of treatment, requiring Medicare Advantage plans to annually review utilization management policies, and requiring coverage determinations be reviewed by professionals with relevant expertise. These proposed policies complement proposals in CMS’ recently announced Advancing Interoperability and Improving Prior Authorization Processes Proposed Rule.

The proposed rule focuses on protecting people exploring Medicare Advantage and Part D coverage from confusing and potentially misleading marketing while also ensuring access to accurate and necessary information to make coverage choices. The proliferation of certain television advertisements generically promoting Medicare Advantage enrollment has been a topic of concern. To address this issue, CMS proposes to prohibit ads that do not mention a specific plan name as well as ads that use words and imagery that may be confusing, or use language or logos in a way that is misleading, confusing, or misrepresents the plan. CMS also proposes to codify guidance protecting people with Medicare or exploring Medicare coverage from misleading marketing and ensure they are not pressured into enrolling into plans that may not best meet their needs. Further, CMS is proposing to strengthen the role of plans in monitoring agent and broker activity.

CMS also is proposing to strengthen behavioral health network adequacy by adding clinical psychologists, licensed clinical social workers, and prescribers of medication for opioid use disorder to the list of evaluated specialties. CMS also proposes new minimum wait time standards for behavioral health and primary care services and more specific notice requirements from plans to patients when these providers are dropped from their networks. Finally, CMS proposes to require most types of Medicare Advantage plans include behavioral health service in care coordination programs, ensuring that behavioral health care is a core part of person-centered care planning. 

Also, for the first time, CMS proposes establishing a health equity index in the Star Ratings program that would reward excellent care for underserved populations by Medicare Advantage and Medicare Part D plans. The rule also proposes updates to the Medicare Part D medication therapy management (MTM) program to improve access, including a proposed requirement that plans include all 10 core chronic diseases identified by CMS — including HIV/AIDS — in their MTM targeting criteria. 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 interpreter standards and the requirement that materials be provided in alternate formats and languages. Finally, the proposed rule would balance the emphasis between patient experience, complaints, and access Star Ratings measures and health outcomes Star Ratings measures to more effectively focus both on patient-centric care and on improving clinical outcomes.