CMS 2021 Proposed Changes to Medicare Advantage & Part D Programs

Last week, the Centers for Medicare & Medicaid Services (CMS) proposed a few major changes to the Medicare Advantage (Part C) and Medicare Part D programs that could influence the way beneficiaries choose and purchase their Medicare coverage and prescription drugs. The goal of these initiatives is to make Medicare Advantage and Part D coverage more affordable for and accessible to beneficiaries, to promote a greater degree of transparency within these programs, and instill a greater degree of confidence in beneficiaries. It’s worth noting that these are only proposed changes; they haven’t been approved or confirmed yet. Also, if approved, the changes would not go into effect until 2021 at the earliest. In fact, one of the most significant changes would only go into effect until 2022.

All facts, quotes, and claims are drawn from CMS’ February 2, 2020, press release “Proposed Changes to Medicare Advantage and Part D Will Provide Better Coverage, More Access and Improved Transparency for Medicare Beneficiaries.”

Prescription Drug Comparison Tool & Cost-Sharing Changes

We think the most significant proposal of this announcement has to do with prescription drug transparency and costs. If approved, the ruling would require Part D plans to offer a real-time drug comparison tool, to go live by January 1, 2022. In theory, with these tools, beneficiaries should be able to look up a drug at the doctor’s office to what they would pay for it or similar drugs. Generally, these tools could help beneficiaries better find generic options that can save them money. At the same time, this type of tool can empower beneficiaries to have a say in their prescriptions, and drug cost, before getting to a pharmacy.

Whether you’re a senior dealing with kidney disease, living in a rural area, facing high costs because you need a specialty drug, or just want a better sense of what you’ll owe for prescription drugs, these new CMS proposals will improve your Medicare experience. — said HHS Secretary Alex Azar.

Another big change proposed that deals with drug costs is related to formulary tiers. The highest cost-sharing tier in most formularies is the specialty drug tier. This proposal would allow for a secondary, “preferred” specialty tier, which would have drugs that are less expensive than those in the top specialty tier. It also would allow Part D plans a greater flexibility in naming tiers, with the hope of lowering cost-sharing for beneficiaries.

CMS is also considering developing measures to reward plans who encourage market utilization of generic drugs, which cost less than brand-name drugs.

Greater Flexibility for Medicare Advantage

On the Medicare Advantage side, one change proposed by this announcement is in relation to the availability of Medicare Advantage plans to enrollees who qualify for Medicare due to End-Stage Renal Disease (ESRD). Currently, ERSD patients have a limited ability to enroll Medicare Advantage plans, leading many to go with Original Medicare. To give these beneficiaries more options, the proposed changes would allow all beneficiaries with ERSD to enroll in a Medicare Advantage plan beginning in 2021.

The proposed changes would allow all beneficiaries with ERSD to enroll in a Medicare Advantage plan beginning in 2021.

The other change proposed for Medicare Advantage deals with telehealth services. The aim of the proposed rule would expand the types of telehealth services that Medicare Advantage plans could cover in regard to psychiatry, neurology, or cardiology. This would expand the care options for seniors who are homebound, living in rural areas, or otherwise may struggle to receive health services.

Enhancing Star Ratings & Pharmacy Evaluation

In addition to the changes we’ve discussed, CMS is focused on increasing the transparency of the quality of Medicare Advantage plans and pharmacies in 2021. They’ve proposed reworking the Star Ratings system to give more weight to beneficiaries’ experiences and their level of access. The justification for this is that user experience is one of the best indicators of a plan’s overall quality.

Currently, plans are not required to disclose how they evaluate pharmacies to CMS.

At the same time, CMS is also proposing to change the way plans evaluate pharmacies’ performances for network agreements. Currently, plans are not required to disclose how they evaluate pharmacies to CMS. The proposal would require plans to disclose this information to CMS so that CMS can track how these measurements are taken and applied. Additionally, this rule would allow CMS to publicly report these metrics for the sake of transparency. It also aims to promote industry standards for evaluation measurements.

Opioid Education & Drug Management Programs

Finally, the other major changes proposed by CMS are related to opioid education. They wish to have Part D plans provide education to beneficiaries on opioid risks, alternate pain treatments, and safe disposal methods for opioids.

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CMS is inviting the public to submit comments and questions on these proposals through Friday, March 6, 2020. After that, the final Rate Announcement will be published by April 6, 2020. You can submit comments on the proposed changes online. To leave a comment, go to www.regulations.gov and search “CMS-2020-0003” to find the page. Once there, follow the instructions on the page to submit a comment.