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CMS NEWS
FOR IMMEDIATE RELEASE
February 5, 2020
Contact: CMS Media
Relations
(202) 690-6145 | CMS Media Inquiries
Proposed Changes to Medicare Advantage and Part D Will Provide
Better Coverage, More Access and Improved Transparency for Medicare
Beneficiaries
Proposed rule and Advance Notice continue to strengthen the
popular private Medicare health and drug plans
Today the Centers for
Medicare & Medicaid Services (CMS) issued a proposed rule and the Advance
Notice Part II to further advance the agency’s efforts to strengthen and
modernize the Medicare Advantage and Part D prescription drug programs. The
changes proposed today would lower beneficiary cost sharing on some of the
most expensive prescription drugs, promote the use of generic drugs, and
allow beneficiaries to know in advance and compare their out-of- pocket
payments for different prescription drugs.
Together, these proposed
changes advance President Trump’s Executive Orders on Protecting and
Improving Medicare for Our Nation’s Seniors and Advancing American Kidney
Health as well as several of the CMS strategic initiatives. The proposed
changes described in the Advance Notice are expected to increase plan revenue
by 0.93%.
“Whether you’re a senior
dealing with kidney disease, living in a rural area, facing high costs
because you need a specialty drug, or just want a better sense of what you’ll
owe for prescription drugs, these new CMS proposals will improve your
Medicare experience,” said HHS Secretary Alex Azar. “President Trump has been
laser-focused on strengthening and protecting Medicare for our seniors, and
these proposed improvements are the latest measures taken under the
President’s Medicare executive order.”
As part of President
Trump’s commitments to promoting price transparency and lowering prescription
drug prices, the proposed rule would require Part D plans to offer real-time
drug price comparison tools to beneficiaries starting January 1, 2022, so
consumers could shop for lower-cost alternative therapies under their
prescription drug benefit plan. For example, beneficiaries would be able to
compare drug prices at the doctor’s office to find the most cost- effective
prescription drugs for their health needs. In addition, if a doctor
recommends a specific cholesterol-lowering drug, the patient could
easily look up what the copay would be and see if a different, similarly
effective option might save the patient money. With this tool, patients would
be better able to know what they’ll need to pay before they’re standing at
the pharmacy cash register, and pharmaceutical companies and plans would have
to compete on the basis of the costs that patients face for their
prescription drugs.
“In addition to giving
those with kidney disease more choices, today’s proposals shed desperately
needed light on previously obscured out of pocket costs for prescription
drugs, “said CMS Administrator Seema Verma. “At the same time, it strengthens
plans’ negotiating power with prescription drug manufacturers so American
patients can get a better deal. The Trump Administration will stop at nothing
to protect America’s seniors.”
In the Medicare Part D
program, beneficiaries choose the prescription drug plan that best meets
their needs. Many plans offering prescription drug coverage place drugs into
different “tiers” on their formularies. Today, all drugs on a plan’s
specialty tier – the tier that has the highest-cost drugs – have the same
level of cost sharing. The proposed rule would allow a second, “preferred”
specialty tier in Part D with a lower cost sharing amount. This proposal is
designed to give Part D plans more tools to lower out of pocket costs for
enrollees. Plans would be able to demand a better deal from manufacturers of
the highest-cost drugs in exchange for placing their products on the
“preferred” specialty tier.
Under the Part D program,
plans currently do not have to disclose to CMS the measures they use to
evaluate pharmacy performance in their network agreements. CMS has heard
concerns from pharmacies that the measures plans use to assess their
performance are unattainable or otherwise unfair. The measures used by plans
potentially impact pharmacy reimbursements. Therefore, the proposed rule
would require Part D plans to disclose such information to enable CMS to
track how plans are measuring and applying pharmacy performance measures. CMS
will also be able to report this information publicly to increase
transparency on the process and to inform the industry in its new efforts to
develop a standard set of pharmacy performance measures. CMS is also seeking
comment on Part D pharmacy performance measures more broadly, including
stakeholders’ recommendations for potential Part D Star Ratings metrics that
could incentivize the uptake of a standard set of measures once the industry
establishes one.
One way to help lower drug
prices for beneficiaries is to encourage greater use of lower price generics
and biosimilars. In general, plans are already achieving high utilization
rates, but there is room to do better. In the Advance Notice, CMS is seeking
comment on potentially developing measures of generic and biosimilar
utilization in Medicare Part D as part of a plan’s star rating. This would
reward plans based on the rate at which they encourage market adoption of
these competitor products and lower costs for patients.
Currently, beneficiaries
with End-Stage Renal Disease (ESRD) are only allowed to enroll in Medicare
Advantage plans in limited circumstances. Today’s proposed rule implements
the 21st Century Cures Act requirements to give all beneficiaries with ESRD
the option to enroll in a Medicare Advantage plan starting in 2021. This will
give patients with ESRD access to more affordable Medicare coverage choices
and extra benefits such as transportation or home- delivered meals.
Starting this year,
Medicare Advantage beneficiaries are able to access additional telehealth
benefits not offered under Medicare Fee-for-Service, giving patients the
option to receive health care services from more convenient locations, like
their homes, rather than requiring them to go to a health care facility. CMS
is proposing to build on the current benefits and give Medicare Advantage
plans more flexibility to count telehealth providers in certain specialty
areas like psychiatry, neurology, or cardiology towards network adequacy
standards, which would encourage greater use of telehealth services as well
as increase plan choices for beneficiaries.
These proposed changes aim
to give seniors more plan choices in rural areas, increase competition
between plans, and allow providers to take advantage of the latest healthcare
technologies and innovations.
CMS is also proposing to
enhance the Medicare Advantage and Part D Star Ratings to further increase
the impact that patient experience and access measures have on a plan’s Star
Rating. The Star Ratings system helps people with Medicare, their families,
and their caregivers compare the quality of health and drug plans being
offered. One of the best indicators of a plan’s quality is how its enrollees
feel about their coverage experience. This proposal reflects CMS’s commitment
to put patients first and improves incentives for plans to focus on what
patients value and feel is important.
Continuing the fight
against the opioid epidemic, the proposed rule implements several provisions
of the Substance Use-Disorder Prevention that Promotes Opioid Recovery and
Treatment (SUPPORT) for Patients and Communities Act that require Part D
plans to educate beneficiaries on opioid risks, alternate pain treatments,
and safe disposal of opioids. The proposed rule also expands drug management
programs and medication therapy management programs, through which Part D
plans review with providers opioid utilization trends that may put beneficiaries
at-risk and provide beneficiary-centric interventions. These provisions will
help prevent and treat opioid overuse.
And finally, as part of
our Patients Over Paperwork initiative to reduce unnecessary burden, increase
efficiencies, and improve the beneficiary experience, in the proposed rule,
CMS is seeking comment on many longstanding policies on the Medicare
Advantage and Part D programs that have been adopted through sub-regulatory
guidance such as the annual Call Letter and other guidance documents. CMS
looks forward to feedback on the proposed rule. Comments may be submitted
electronically through our e-Regulation website at: https://www.cms.gov/Regulations-and-Guidance/Regulations-and-
Policies/eRulemaking/index.html?redirect=/eRulemaking.
CMS will accept comments
on all proposals in the Advance Notice through Friday, March 6, 2020, before
publishing the final Rate Announcement by April 6, 2020. To submit comments
or questions electronically, go to www.regulations.gov, enter the docket
number “CMS-2020-0003” in the “search” field, and follow the instructions for
‘‘submitting a comment.’’
For a fact sheet on the CY
2021/2022 Medicare Advantage and Part D Proposed Rule (CMS- 4190-P), please
visit: https://www.cms.gov/newsroom/fact-sheets/contract-year-2021-and-2022-medicare-advantage-and-part-d-proposed-rule-cms-4190-p-1
The proposed rule can be
downloaded from the Federal Register at: https://www.federalregister.gov/documents/2020/02/18/2020-02085/medicare-and-medicaid-
programs-contract-year-2021-and-2022-policy-and-technical-changes-to-the
The 2021 Medicare
Advantage and Part D Advance Notice Part II Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/2021-medicare-advantage-and-part-d-advance-notice-part-ii-fact-sheet-0
Medicare Advantage and
Part D Advance Notice Part II, please visit:
A blog about Increasing
Access to Generics and Biosimilars in Medicare will be available at
https://www.cms.gov/blog/increasing-access-generics-and-biosimilars-medicare
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Get CMS news at cms.gov/newsroom, sign up for CMS news via email and follow CMS on Twitter CMS
Administrator @SeemaCMS, @CMSgov, and @CMSgovPress
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Wednesday, February 5, 2020
Proposed Changes to Medicare Advantage and Part D Will Provide Better Coverage, More Access and Improved Transparency for Medicare Beneficiaries
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