Proposed rule strengthens equity and behavioral health in Medicare Advantage program

Photo: Justin Paget/Getty Images

For the first time, the Center for Medicare and Medicaid Services is proposing to establish a health equity index in the Medicare Advantage and Part D Star Ratings program that would reward excellent care for underserved populations. The proposed rule would also update the Medicare Part D medication therapy management program to require that plans include all 10 core chronic diseases identified by CMS – including HIV/AIDS – in their medication therapy management 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, CMS said.

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

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

Individuals with incomes up to 150% of the federal poverty level and who meet statutory resource requirements will qualify for the full low-income subsidy beginning on or after January 1, 2024. Eligible enrollees will have no deductible, no premiums (if enrolled in a "benchmark" plan), and fixed, lowered copayments for certain medications.

WHY THIS MATTERS

The proposed rule is being released after CMS received close to 4,000 comments regarding improvement to the Medicare Advantage program from a July Request for Information. Comments on the proposed rule are due by February 13, 2023.

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

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

These proposed policies complement proposals in CMS' recently announced Advancing Interoperability and Improving Prior Authorization Processes Proposed Rule released earlier this month.

Additionally, the proposed rule focuses 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 topic of concern, CMS said. 

To address this, CMS said it 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 or confusing, or that 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.

THE LARGER TREND

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

In line with CMS' Behavioral Health Strategy and the Administration's strategy to address the national mental health crisis, CMS proposes 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. 

CMS also proposes to require most types of Medicare Advantage plans include behavioral health services in care coordination programs, so ensuring that behavioral healthcare is a core part of person-centered care planning. 

ON THE RECORD

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

Twitter: @SusanJMorse
Email the writer: SMorse@himss.org