CMS has finalized or proposed several policy changes in 2023, including stricter audits of Medicare Advantage plans, changes to prior authorization and regulations aimed at drug prices.
Here are seven key policies from the agency to note from the first half of 2023:
- CMS is proposing a new rule for drug manufacturers, pharmaceutical benefit managers and managed care plans to increase drug price transparency in Medicaid. The agency laid out plans to increase transparency by requiring manufacturers to disclose some pricing information through a price survey and requiring PBMs to disclose more pricing details to managed care plans. The proposal is open for comment through July 25.
- Two rules proposed by CMS would establish national standards of care provided through fee-for-service Medicaid/CHIP and managed care plans, and require Medicaid managed care plans to disclose provider payment rates online. The proposal is open for comment through July 3.
- CMS upped the number of nonstandard ACA plans payers can offer in each region from two to four. In a final rule, the agency upped the cap on nonstandard plans, added new special exchange enrollment periods for people who have lost Medicaid coverage and established more stringent network requirements for plans.
- In April, CMS issued a final rule that aimed to streamline Medicare Advantage and Part D prior authorizations and clamp down on misleading marketing practices. The rule requires that coordinated care plan prior authorization policies may only be used to confirm the presence of diagnoses or other medical criteria and/or ensure that an item or service is medically necessary.
- CMS is moving ahead with Medicare Advantage risk adjustment changes payers and some provider groups opposed, but the agency will phase in the model over three years. The agency will shift MA's diagnosing coding from ICD-9 to ICD-10 and remove certain codes from the Hierarchical Condition Categories model, in addition to other changes to risk adjustment payments.
- CMS laid out more details on how it plans to implement the first-ever negotiation process of drug prices under Medicare, which will first apply in 2026, including a timeline. The agency plans to publish updated guidance based on feedback in summer 2023.
- CMS will implement stricter audits of Medicare Advantage plans, a move that could leave payers on the hook for billions of dollars in repayments to the federal government. In a final rule issued Jan. 30, the agency said it will strike the fee-for-service adjuster from risk adjustment data validation audits, a tool that would have calculated a permissible level of payment errors and limited audit recoveries to payment errors above that level.