CMS proposes rule to further overhaul Medicare Advantage marketing, prior authorization

CMS issued a proposed rule Dec. 14 to continue its efforts to overhaul prior authorization and marketing practices around Medicare Advantage and Part D plans, along with adding health equity measures to star ratings and boosting behavioral health network adequacy requirements.

The proposed rule would also implement a key prescription drug affordability provision of the Inflation Reduction Act.

"From streamlining prior authorization to cracking down on misleading marketing, we are committed to ensuring that everyone can have peace of mind and get the health care they need." HHS Secretary Xavier Becerra said in a news release.

Comments on the proposal are due by Feb. 13. Read the full proposal here.

Prior authorization

The proposed rule would require an approved prior authorization request to remain valid for a member's entire course of treatment and require coverage determination to be reviewed by relevant professionals. MA plans would also have to create a committee to review their utilization management policies every year and ensure they align with traditional Medicare’s national and local coverage guidelines.

According to CMS, the rule builds on another recent proposal to support electronic prior authorization processes.

Marketing practices

Generic MA marketing is "a topic of concern" for the agency, so the proposed rule would ban advertisements that don't mention a specific plan, along with those that use confusing words and imagery that misrepresent a plan.

The rule would also newly codify previous guidance around high-pressure marketing, including a ban on sales presentations that immediately follow an educational event.

The proposal comes on the heels of another new marketing policy for MA and Part D plans that bans advertising on television without agency approval first, starting in 2023.

Health equity 

CMS is looking to include a health equity index in its star ratings program starting in 2027 using measurement data from 2024 and 2025.

"CMS also proposes to reduce the weight of patient experience/complaints and access measures by half (from four to two) to further align with other CMS quality programs and the current CMS Quality Strategy that promotes quality outcomes," the agency wrote.

The rule would also look to improve provider directories, particularly for non-English speakers, through new interpreter standards and alternate format requirements.

Behavioral health

Under the rule, clinical psychologists, licensed clinical social workers, and prescribers of medication for opioid use disorder would be added to the list of specialties evaluated for network adequacy. CMS is also proposing minimum wait times for behavioral and primary care services and a requirement to notify members when those providers are dropped from a network. 

The rule would also require most MA plans to establish care coordination programs that include behavioral health.

Prescription drugs

The rule would allow Part D providers to substitute a new biologic for its corresponding reference product, a new unbranded biologic for its corresponding brand name biologic, and a new authorized generic for its corresponding brand name equivalent without agency approval.

Under the Inflation Reduction Act, members with incomes up to 150 percent of the federal poverty level and who meet certain resource requirements will qualify for the low-income subsidy program beginning Jan. 1, 2024. 

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