CMS seeks to pass Part D price reductions to beneficiaries

CMS on Thursday proposed developing rules that would shift pharmaceutical price concessions to beneficiaries of Medicare Part D plans and make the medical wastage ratio in Medicare Advantage plans more robust.

CMS on Thursday proposed draft rules aimed at Medicare Advantage (MA) transparency, including improvements for beneficiaries who are doubly eligible, and changes to Part D, including the transfer of any price concessions received. from pharmaceutical companies to beneficiaries at the pharmacy counter.

“We are committed to ensuring that older Americans and people with disabilities served by the Medicare program have access to quality, affordable health care, including prescription drugs and therapies,” CMS Administrator said , Chiquita Brooks-LaSure, in a statement. “The actions proposed today follow our guiding principles by improving health equity and improving access to prescription drugs.

In a fact sheet, CMS wants Part D plans that have agreements with certain pharmacies, where they pay less for drugs if parameters are not met, to share the savings with beneficiaries by applying those savings to the negotiated price of the drug.

The agency is also proposing to redefine the negotiated price as the lowest eligible payment at a pharmacy, effective January 1, 2023.

In the proposed rule, CMS said Plan D costs to beneficiaries would be reduced by 2%, or $ 21.3 billion over 10 years. However, the plan would cost the government $ 40 billion during this period due to the increase in direct grants and bonus payments to low incomes, which is a 3% increase. Drugmakers would save about $ 14.6 billion, CMS said.

CMS said the move “would reduce out-of-pocket expenses for Medicare Part D beneficiaries and improve price transparency and market competition under the Part D program.”

For beneficiaries eligible for both Medicare and Medicaid, CMS seeks to improve the information they receive in an effort to achieve health equity and reduce health disparities.

The proposed rule would require MA organizations with Dual Qualifying Special Needs Plans (D-SNPs) to establish, maintain and consult one or more registered advisory committees to include the voices of those beneficiaries, who tend to be low-income. and have more chronic problems. diseases. The proposal would streamline complaints and appeals processes in some D-SNPs, simplify information on access to services, and change the cost-sharing of MA to improve payments to providers serving this population.

Beneficiaries should be asked about their barriers to accessing care through standardized questions in the required health risk assessments on housing instability, food insecurity and transportation. CMS would strengthen oversight of third party marketing organizations that act, directly or indirectly, on behalf of MA organizations and Party D sponsors by demanding free translation services.

In addition, requests for new or extended MA plans must show that they have a sufficient network of contracted suppliers. If previous performance was poor, MA’s plans could not expand.

Another part of the rule would increase what MA and Party D must report on their Medical Loss Report (MLR). MLR is the share of premiums spent on medical care; currently, plans must meet an MLR of 85%.

The proposal would require reporting the underlying cost and revenue information needed to calculate and verify the MLR percentage and payout amount, which was the case from 2014 to 2017.

Additionally, if the rule is passed, plans should include amounts spent to provide additional benefits (dental, vision, hearing, transportation, and meals) that are not provided in traditional fee-for-service health insurance. .

Comments are closed.