Medicare Advantage/Part D Proposal Addresses Misleading Marketing, Promotes Equity in Prior Authorization Policies and Improved Access to Care

November 7, 2023

On November 6, 2023, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that would update Medicare Advantage (MA), the Medicare Prescription Drug Benefit Program (Part D), the Medicare Cost Plan program, Programs of All-Inclusive Care for the Elderly (PACE), and the Health Information Technology Standards and Implementation Specifications in 2025. The proposed policies aim to strengthen beneficiary protections from misleading marketing, promote equity in coverage, improve prior authorization, promote access to behavioral health care providers, and improve supplemental benefits. Important provisions for the cancer care community are listed below.

Adding Health Equity Perspective to Prior Authorization: CMS is proposing to require health plans to analyze their prior authorization and other utilization management (UM) protocols from a health equity perspective. The goal of the health equity analysis is to create additional transparency and identify disproportionate impacts of UM policies and procedures on enrollees who receive the Part D low-income subsidy, are dually eligible, or have a disability.

Biosimilar Biological Product Substitution: CMS is proposing to permit Part D sponsors to substitute biosimilar biological products that are not interchangeable on formularies, for their reference product without prior approval by CMS. The agency would consider such substitutions “maintenance changes.” Treating these substitutions as maintenance changes would mean that any substitutions would apply to all enrollees, including those already taking the reference product prior to the effective date of the change, following a 30-day notice.

New Agent and Broker Requirements:  In an attempt to crack down on false or misleading marketing practices that steer Medicare beneficiaries towards MA plans that they may not want or completely understand, CMS is proposing to limit the amount that third-party agents and brokers can be paid by plans. CMS is also proposing to prohibit contract terms that allow such “middlemen” to receive bonuses based on the number of beneficiaries that enroll in certain plans.

Behavioral Health Access Requirements: CMS is proposing updates to network adequacy standards for “Outpatient Behavioral Health,” which includes marriage and family therapists, mental health counselors, Opioid Treatment Program providers, Community Mental Health Centers, addiction medicine physicians, and other providers who furnish addiction medicine and behavioral health counseling or therapy services in Medicare today.

Increasing the Number of Dually Eligible Managed Care Enrollees Who Receive Integrated Medicare and Medicaid Services: To help align coverage for beneficiaries who are enrolled in both Medicare and Medicaid, CMS is proposing to create a once-per-month special enrollment period to allow dually eligible individuals to elect an integrated dual eligible special needs plan (D-SNP).  The proposal also includes separate provisions related to D-SNPs.

ASCO will submit comments on the proposed rule by the due date on January 5, 2024.

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