Changes proposed to Medicare Advantage, Part D programs

The Centers for Medicare and Medicaid Services proposed changes to reduce prescription drug costs for Medicare Advantage and Medicare Part D enrollees.

These changes aim to increase affordability, expand care coordination and address the health disparities for seniors and those with disabilities while ensuring higher insurer accountability.

"We continue to hear from people enrolled in Medicare Advantage who are having difficulty accessing the care they need and are entitled to, and CMS remains focused on removing these barriers," said Dr. Meena Seshamani, CMS deputy administrator and director of the Center for Medicare.

Seshamani said that no senior or person with disabilities on Medicare should be having difficulties navigating options, being able to afford medications prescribed by doctors, or receiving the inpatient or rehabilitation care needed.

Policies included in the proposed rule remove barriers to care due to prior authorization and ensuring guardrails for the use of artificial intelligence to protect access to health services while promoting access to behavioral health care providers.

"Our loved ones with Medicare deserve care that puts their interests first. HHS is proposing to improve transparency, accountability, and consumer protections in Medicare Advantage and Part D plans so that everyone receives high-quality care," said Health and Human Services Secretary Xavier Becerra in a news release.

He continued, "To achieve that, we want to remove barriers that delay care or deny people services and medications they need to be healthy. In addition, we continue to promote competition for pharmacies and other healthcare businesses."

The change would lower out-of-pocket costs for weight loss drugs like Wegovy, Ozempic, and Mounjaro, among others that cost upward of $1,000 a month, which have only been covered when they are used to treat conditions like diabetes.

The coverage of anti-obesity medication, now that the medical consensus has changed and lists obesity as a disease, has resulted in CMS proposing to "reinterpret" the statute that currently excludes anti-obesity medications for the treatment of obesity for those covered under Medicare Part D.

The CDC reports obesity in 40.3% of adults in the U.S.

CMS stated it "would continue to exclude anti-obesity medications from Part D coverage when being used in individuals who are overweight but without obesity or another condition that is a medically accepted indication."

However, because the proposal reinterprets the Medicaid statute, it would also apply to the Medicaid program.

Enhancements to Medicare Advantage include improving payment accuracy by updating the risk adjustment model and aligning it with the current healthcare coding standard.

The proposals emphasize the adjustments to streamline coverage while reducing out-of-pocket costs for prescription drugs.

CMS proposed four modifications to strengthen existing regulations:

Clarify that the enrollee's further liability to pay for services cannot be determined until an MA organization has decided on a request for payment.Clarify that a coverage decision is made by an MA organization when an enrollee is receiving inpatient or outpatient coverage.Strengthen the notice requirements of the MA organization's decision.A change to reopening rules eliminates an MA organization's discretion when reopening an approved authorization for an inpatient hospital admission.