CMS Proposed Rule: Prescription Drug Costs in MA and Part D Plans

The Centers for Medicare and Medicaid Services (CMS) announced a new proposed rule that takes aim at prescription drug costs in Medicare Advantage (MA) and Medicare Part D plans. The agency said the rule would reduce out-of-pocket costs for beneficiaries and improve price transparency as well as “market competition in the Part D program.”

One proposal would rectify a growing practice in Part D plan negotiation that results in discrepancies between a negotiated drug price reported to CMS and what pharmacies are actually paid. Becker’s reports that the rule would redefine the lower negotiated price as the new baseline.

It also includes regulations on third-party marketing for Medicare Advantage and Part D plans by targeting “deceptive marketing tactics” and changing some disclaimers. MA plans will also be required to comply with special requirements during a public health emergency if there is a disruption to care.

According to the American Journal of Managed Care, CMS wants to improve information for beneficiaries who qualify for both Medicare and Medicaid. The proposed rule would require that MA organizations with Dual Eligible Special Needs Plans (D-SNPs) to establish enrollee advisory committees that must by nature include some beneficiaries. This would streamline the grievance and appeals process for D-SNPs and simplify information about accessing services.

CMS says that the rule is part of the Biden administration’s larger project of health equity, and would require D-SNP advisory committees to ask beneficiaries about their barriers to accessing care through standard questions in health risk assessments that include topics like housing instability, food insecurity and transportation. From CMS Administrator Chiquita Brooks-LaSure, via the CMS Press Release:

We are dedicated to ensuring older Americans and those with disabilities who are served by the Medicare program have access to quality, affordable health care, including prescription drugs and therapies. Today’s proposed actions follow our guiding principles by impacting health equity and enhancing access to prescription medications.

CMS Fact Sheet: CY 2023 Medicare Advantage and Part D Proposed Rule