Latest News on the Medicare Advantage Program

CMS reinforces the transparency of Medicare Advantage

The Medicare and Medicaid Service Centers issued a final rule with policies designed to provide greater transparency for Medicare Advantage and Part D plans.

The final Medicare Advantage and Part D rule of 2023 also advances more affordable health care, CMS said, reducing the out-of-pocket costs of prescription drugs from 2024.

CMS finalized the policy requiring Part D plans to apply all price concessions they receive from network pharmacies at the bargain price at the point of sale. This means that the beneficiary can share the savings, CMS said, because the policy reduces the beneficiary’s out-of-pocket costs and improves price transparency and market competition in the Part D program.

Specifically, CMS is redefining the negotiated price as the reference payment, or as low as possible, to a pharmacy, as of January 1, 2024.

Matt Eyles, president and CEO of AHIP, a trade association for health insurers, said: “As we continue to review the final rule, we are very disappointed that CMS has not withdrawn its proposal to require all possible pharmacy price concessions at a negotiated price at the point of sale of the Part D plan. Only pharmacists benefit from this requirement, with the elderly and taxpayers paying the price through higher premiums. CMS is delaying the implementation of the rule until 2024, so that sponsors of the Part D plan and health insurance providers will have time to try to mitigate the impact on the elderly. ”

The standard also clarifies policies to provide beneficiaries enrolled in MA plans with uninterrupted access to services needed during disasters and emergencies, such as the COVID-19 pandemic.

Another policy revises the marketing requirements to strengthen the oversight of third-party organizations of potentially misleading activities to enroll members.

To strengthen network adequacy standards, MA applicants must demonstrate that they have a sufficient network of contracted providers to serve beneficiaries before CMS approves an application for a new or expanded contract.

The final rule adds a star rating of 2.5 or lower, bankruptcy or bankruptcy, and exceeding designated thresholds for compliance actions as grounds for CMS to deny a new application or area expansion application on duty.

Promote the sustainability of the Medicare program. CMS is re-establishing medical loss ratio reporting requirements and expanding reporting requirements for additional MA benefits.

“This will improve transparency in the underlying costs, revenues and additional benefits of the MA and Part D plans, which will benefit beneficiaries and taxpayers,” CMS said.

CMS is re-establishing the medical loss ratio reporting requirements that were in effect from 2014 to 2017. This requires the MA and Part D plans to report the underlying cost and revenue information needed to calculate and verify the MLR percentage. and the amount of the remittance, if any.

In addition, plans will need to report the amounts they spend on various types of additional benefits that are not available with original Medicare.

CMS is finalizing a technical change to allow CMS to calculate the Part C star ratings for 2023 for the three measures of the Health Effectiveness Information and Data (HEDIS) set collected through the results survey. health: monitoring physical activity; Reduction of the risk of falling; and Bladder control.

Without this technical change, CMS would not be able to calculate the 2023 star ratings for these measures for any MA contract, as all contracts meet the requirements for the adjustment of extreme and uncontrollable circumstances for COVID-19, said CMS.

CMS is also finalizing a number of changes that were set out in the provisional final rule COVID-19 of March 31, 2020 and the provisional final rule COVID-19 of September 2, 2020 in the star ratings of 2021 and 2022 to adapt to the interruption that data collection entailed. due to the COVID-19 pandemic.

The rule also strengthens coordination between states and the CMS to care for people who are doubly eligible for Medicare and Medicaid. This includes coding a mechanism by which states can require double eligible special needs plans that use integrated materials that make it easier for people with dual rights to understand the full scope of their Medicare and Medicaid benefits.

The rule also requires that all MA special needs plans annually assess certain social risk factors for their enrollees because identifying social needs is a key step in providing person-centered care.

In addition, CMS is closing a gap for doubly eligible MA enrollees who have high medical costs that exceed the maximum payment limit set by the MA plan. This gap had resulted in a lower payment to providers serving doubly eligible MA registrants than providers serving non-doubly eligible MA registrants.


CMS released the rule on the day the Office of the Inspector General released an unfavorable report on Medicare Advantage denials of prior authorization, compared to original Medicare. MAOs also denied payments to providers for some services that complied with both Medicare coverage rules and MAO billing rules, according to the report.

CMS made no mention of the OIG report, but the agency made it clear that it wants to know where MA government plans spend their government money, both for reasons of transparency and better support for social determinants. health.

“Tax management is a central principle of the work we do every day,” said Dr. Meena Seshamani, CMS Deputy Administrator and Director of the Medicare Center. “As program administrators, this rule allows us to learn more about how the Medicare dollar is spent on certain Medicare Advantage benefits, such as housing, food and transportation assistance, to better understand how we can support more effectively the health and social needs of people with Medicare. ”


CMS said dual eligibility for Medicare and Medicaid is a predictor of social risk and poor health outcomes. Many people with dual eligibility experience challenges such as housing insecurity and homelessness, food insecurity, lack of access to transportation, and low levels of health literacy.

The final rule will help close health disparities by providing integrated person-centered care that can lead to better health outcomes for enrollees and improve the operational functions of these programs, CMS said.

Comments are closed.