Beneficiary Protections, Efforts to Reduce Disparities Finalized in Medicare Advantage and Part D

May 9, 2022

On Friday, April 29, 2022, the Centers for Medicare & Medicaid Services (CMS) released the Contract Year 2023 Policy and Technical Changes to the Medicare Advantage (MA) and Medicare Prescription Drug Benefit Programs final rule. The rule finalizes the administration’s efforts to improve consumer protections, reduce disparities, and improve equity in the MA and Medicare Part D programs in 2023 and beyond.

Pharmacy Price Concessions

CMS is finalizing a policy that requires Part D plans to apply all price concessions received from network pharmacies, including performance penalties, to the negotiated price at the point of sale, effective January 1, 2024. While the Association for Clinical Oncology (ASCO) supported CMS’ proposal to redefine the term negotiated price, thereby reducing beneficiary cost-sharing at the point of sale, we strongly disagree with the continued Pharmacy Benefit Manager-application of CMS’ Star Rating System, which unfairly and unjustifiably penalizes oncology practices and practice-based pharmacies.

Dual Eligible Special Needs Plans (D-SNPs)

An increasing number of beneficiaries who are dually eligible for both Medicare and Medicaid are enrolled in MA plans, Medicaid managed care, or both. About 4.1 million dually eligible beneficiaries currently receive Medicare services through MA D-SNPs. ASCO applauds CMS for finalizing proposals that will improve protections for these beneficiaries and advance health equity in MA and Part D.

For example, in 2023 D-SNPs will be required to establish and maintain one or more enrollee advisory committees and to consult with the advisory committees on various issues, including ways to improve access to covered services and to advance health equity for underserved populations.

Additionally, the maximum out-of-pocket limit in a D-SNP plan will be based on all cost-sharing paid by the beneficiary, Medicaid, other secondary insurance, or remains unpaid. CMS estimates this will save state Medicaid agencies $2 billion over ten years while increasing payment to providers serving dually eligible beneficiaries by $8 billion over ten years.

ASCO strongly supported CMS’ proposal to require initial and annual health risk assessments (HRAs) to include standardized questions on enrollees’ social determinants of health, as these are important factors in an individual’s overall health. CMS finalized a requirement that all SNP HRAs include at least one question from a list of screening instruments specified by CMS on housing insecurity and homelessness, food insecurity, and lack of access to transportation. CMS is not requiring that all SNPs use the same questions.

Network Adequacy

People with cancer and cancer survivors are a particularly vulnerable subset of the population, and they require timely access to cancer specialists, facilities, and supportive care. As ASCO recommended in comments to CMS, beginning in 2023 the agency will require MA applicants to demonstrate they have a sufficient network of contracted providers to care for beneficiaries before CMS will approve an application for a new or expanded MA contract. MA organizations should provide an adequate network of providers to deliver care to all MA enrollees.

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