On April 12, 2023, the Centers for Medicare & Medicaid Services (CMS) published Final Rule CMS-4201-F Contract Year 2024 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicare Cost Plan Program, and Programs of All-Inclusive Care for the Elderly. That long title brings with it a lengthy list of revisions to the Medicare Prescription Drug Benefit (Part D).
Here are the top 10 changes from 4201-F that may impact your plan as they deal with coverage criteria, marketing and communications, Star Ratings, health equity, behavioral health and more.
Coverage Criteria
➀ Requires Medicare Advantage Plans (MAP) to comply with the coverage and benefit conditions included in traditional Medicare regulations.
➁ Clarifies that Medicare Advantage organizations may create internal coverage criteria based on evidence in widely used, publicly available treatment guidelines or literature and lays out the conditions that allow a MAP to apply that internal coverage criteria to make coverage decisions.
➂ Modifies prior authorization requirements to reduce disruptions for beneficiaries. This includes a 90-day transition period for enrollees of a coordinated care plan to switch to a new MAP. During the transition period, if the beneficiary was actively undergoing treatment, the new MAP may not require prior authorization for that treatment.
➃ Requires MAPs to establish Utilization Management Committees to review policies annually and ensure consistency with traditional Medicare’s coverage guidelines.
Marketing and Communications
➄ Implements requirements designed to make ads less confusing and misleading. CMS finalized 21 of the 22 provisions. (17 of them as proposed; 4 with modifications that related to agents and their interactions with beneficiaries)
➅ Sets requirements related to communication with plan enrollees. Plan sponsors must ensure that enrollees receive materials in any non-English language that is the primary language of at least 5% of the individuals in a plan benefit package service area or any other auxiliary aids or services upon receiving a request or otherwise learning of the enrollee’s preferred means of communication. Sponsors must also provide all beneficiaries the comprehensive medication review written summary as well as safe drug disposal information.
Star Ratings
➆ Finalizes methodological enhancements related to the health equity index reward beginning with the
2027 Star Ratings.
- Reduces the weight of the patient experience/complaints and access measure in Star Ratings
- Includes an additional rule for the removal of Star Ratings measures
- Removes the 60% rule related to the adjustment for extreme and uncontrollable circumstances
Health Equity
➇ Clarifies rules and expands the list of populations that Medicare Advantage organizations must provide services to in a culturally competent manner.
The list includes people:
- With limited English proficiency or reading skills
- Of ethnic, cultural, racial or religious minorities
- With disabilities
- Who identify as lesbian, gay, bisexual or other sexual orientation
- Who identify as transgender, nonbinary, and other gender identities
- Who live in rural areas or areas of high levels of deprivation
- Who are otherwise adversely affected by poverty or inequality
➈ Explains requirements for Medicare Advantage organization to offer digital health education to increase access to covered telehealth benefits.
Behavioral Health
➉ Strengthens network adequacy requirements as they relate to behavioral health services by:
- Amending general access to services standards to include behavioral health services
- Changing prior authorization requirements for behavioral health
- Requiring Medicare Advantage organizations to establish care coordination programs
But wait, there’s more…
The rule implements provisions to the Bipartisan Budget Act of 2018, the Consolidated Appropriations Act of 2021 and the Inflation Reduction Act of 2022. The provisions include:
- Making permanent the Limited Income Newly Eligible Transition Program.
- Expanding Low-Income Subsidies under Part D to individuals with incomes up to 150% (up from the current 135%) of the federal poverty level who meet eligibility criteria. Beginning January 1, 2024, this will provide the full low-income subsidy to those who currently qualify for the partial subsidy.
Elixir has reviewed the Final Rule to assess applicability to PBM activities and is preparing for implementation effective January 1, 2024. This includes working with plans to ensure that enrollees receive materials in any non-English language that is the primary language of at least 5% of the individuals in a plan benefit package service area or any other auxiliary aids or services upon receiving a request or otherwise learning of the enrollee’s preferred means of communication. Part D sponsors must also provide all beneficiaries the comprehensive medication review written summary, as well as safe drug disposal information.
Elixir will continue to monitor these topics and all announcements from CMS and their impact to the Medicare prescription drug benefit. Please contact your designated Elixir Account Team or Compliance Officer for more information.
