Proposed Rules Offer New Flexibility to Medicare Advantage Plans

Regulation | November 29, 2017 | by Nicole Fallon

CMS proposes greater flexibility and more streamlined administrative processes for Medicare Advantage and Prescription Drug plans in its recently proposed rules governing calendar year 2019 and beyond.

While the proposed rules cover a number of items related to plan administration and beneficiary notifications, below are a few key proposals that will likely have the greatest impact on providers and people who enroll in the plans:

  • Permit benefit differentiation by health status or disease: The current Medicare Advantage (MA) regulations require plans to offer their plan to all Medicare beneficiaries in a service area with a uniform premium, benefits, and cost sharing for every enrollee. The proposed rules reflect a reinterpretation by CMS of these provisions. Under the proposed rule, MA plans could meet the uniformity requirements even in cases where the plan offers: reduced cost sharing for certain covered benefits, tailored supplemental benefits for certain health care needs, and lower deductibles for enrollees with certain medical conditions. In other words, a MA plan may offer a different set of benefits to enrollees with a certain medical condition (e.g., diabetes, COPD, etc.) that would not be available to an enrollee that did not have that condition. For example, an enrollee with diabetes might be eligible for no cost sharing for visiting their endocrinologist or coverage fpr additional foot exams whereas these benefits would not be available to someone without diabetes. CMS stresses that any plan exercising this option must ensure that the cost sharing reductions and targeted supplemental benefits are for services are medically related to the individual’s disease.
  • CMS also proposes to allow plans to differentiate their benefits, cost sharing, and premiums by county within the plan’s service area.
  • Enrollment issues
    • CMS is proposing to codify the practice of seamless conversions of newly Medicare-eligible individuals through a default enrollment process under the following conditions: 1) the individual is currently enrolled in an Medicaid managed care plan and is dually eligible; 2) the state supports default enrollments; 3) the individual is enrolled into a dual eligible special needs plan (D-SNP) owned by the same parent organization as the Medicaid managed care plan; 4) the individual does not opt out; and 5) the plan has CMS approval to use the default process. CMS believes this approach encourages better integration of care for the individuals. Plans must notify consumers of this proposed default enrollment at least 60 days prior to the effective date.
    • Proposes to change the open enrollment period for those currently enrolled in a Medicare Advantage plan (to comply with the 21st Century Cures Act)and would shift the Part D Special Enrollment Periods (SEP) for Duals and Low-Income Subsidy Beneficiaries from an open-ended monthly SEP to either: 1) a designated period of time after CMS or state-initiated enrollment; or 2) a one-time annual opportunity that could be used at any point during the year. This would provide Part D plans with more predictability in their plan enrollment allowing for improved coordination with other Medicare and Medicaid benefits.  The churn of enrollment changes has been a long-standing concern for Part D plans.
  • Changes to the Days’ Supply Required by Part D Transition Process: The law has required that Part D plan sponsors provide an appropriate transition process when an individual is prescribed a drug not on the plan’s formulary (including drugs requiring prior authorization or step therapy). For long-term care settings, this transition supply has been set at up to 90 days or more. CMS is proposing to standardize the transition supply provided in long-term care settings to be the same as required in outpatient settings. This new standard will require the plan sponsors to provide up to a one-month, temporary supply of the non-formulary drug. Long Term Care Facility-based pharmacies should take note of this proposed change in policy.
  • Provides Part D plans with additional time (up to 14 days) to process payment appeal requests at the redetermination and independent review entity reconsideration levels.

Comments on the rules are due to CMS by January 16, 2018 at 5 p.m.and may be submitted here.   An article summarizing some changes contained in the rule impacting PACE programs was posted previously.