CMS proposes new Medicare Advantage and Part D reforms on prior authorization, marketing

The Biden administration released a proposal to streamline Medicare Advantage (MA) and Part D plan prior authorization and add health equity requirements to star ratings.

The Centers for Medicare & Medicaid Services (CMS) released a proposed rule Wednesday outlining policies for MA and Part D plans for the 2024 coverage year and implementing drug price provisions in the Inflation Reduction Act. It is the latest move by the Biden administration to address prior authorization, a key source of administrative burden for doctors, and to address misleading marketing.

“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 healthcare they need,” said Department of Health and Human Services Secretary Xavier Becerra. 

CMS proposed to clarify when and how MA plans can use prior authorization, where an insurer must approve items or services before a physician can dispense them. The rule would clarify that a granted prior authorization approval shall remain valid for “an enrollee’s full course of treatment, requiring MA plans to annually review utilization management policies and requiring coverage determinations be reviewed by professionals with relevant experience,” according to a release. 

If an item or service doesn’t have an applicable coverage determination from Medicare, then an MA plan must “include current evidence in widely used treatment guidelines or clinical literature made publicly available to CMS, enrollees and providers when creating internal clinical coverage criteria,” according to a fact sheet on the rule.

Any physician or expert used by the MA plan must also have expertise in the field of medicine that “is appropriate for the service to be involved before the MA plan can deny coverage,” CMS added. 

MA plans must also create a new Utilization Management Committee that reviews prior authorization policies annually to ensure consistency with national and local guidelines. 

The proposed changes come as CMS has also recently proposed to expand the use of electronic prior authorization for MA plans and install short turnaround times for commonly approved requests. 

The agency is including new flexibilities for Part D plans to offer biological products and authorized generics on their formularies. CMS is proposing to allow Part D sponsors to immediately substitute a new biologic for its reference product and a new authorized generic for the brand name equivalent in a bid to control costs without having to get CMS approval.

Strengthening star ratings and equity

The rule would include a health equity index for the 2027 star ratings for MA and Part D plans. Such an index will rely on data from 2024 and 2025 measurement years and further encourage MA and Part D plans to work to address social risk factors for patients, a fact sheet said. 

Under the new methodology, CMS would reduce the weight of “patient experience/complaints and access measures to further align efforts with other CMS quality programs,” the rule said. 

It would also codify best practices for MA plans to use in developing provider directories, such as incorporating “non-English languages spoken by each provider and provider/location accessibility for people with physical disabilities.”

The rule would also seek to improve the quality of provider directories, especially for non-English speaking beneficiaries.

CMS specified that MA plans and Part D sponsors must offer materials to enrollees on a “standing basis” in any non-English language that is the primary language of at least 5% of the individuals in the plan’s service area. Under federal law, MA and Part D plans have to offer such materials but only upon request from the beneficiary. 

But CMS “has learned from oversight activities, enrollee complaints and stakeholder feedback that enrollees often must make a separate request each time they would like a material in an alternative language or need auxiliary aids or services,” the rule said. 

CMS previously explored adding health equity requirements to star ratings but tabled the issue after proposing it in the last advance notice. 

Cracking down on marketing

MA marketing tactics have been the subject of scrutiny on Capitol Hill as Sen. Ron Wyden, D-Oregon, released a report that showed complaints are on the rise in nine states

CMS is proposing to ban any television ads that don’t mention a “specific plan name.” It would also prohibit a plan from using the Medicare name or logo that may confuse or mislead beneficiaries. It would also ban sales presentations that follow an educational event and ban the use of Medicare language or logos that make it appear the advertisements are from the government. 

Wyden and Sen. Bob Casey, D-Pennsylvania, heralded the new requirements. 

“These proposals are an important step towards protecting seniors in Medicare from scammers and unscrupulous insurance companies and brokers,” Wyden said in a statement.

CMS previously issued guidance in October that required all MA television ads to get agency approval before hitting the airwaves.