Keeping up with rule and policy changes from the Centers for Medicare and Medicaid Services (CMS) is just part of life for Medicare Advantage Part D (MAPD) plans. Recently, however, two in particular are signaling a shift to in the industry: CMS-4180-P and CMS-4185-P. Should these rules, and others like them, become final, MAPD plans and their beneficiaries will notice substantial changes. Here’s what health plan leadership needs to know:
Medicare Advantage and Part D Drug Pricing Proposed Rule (CMS-4180-P)
This rule (CMS-4180-P, proposed Nov. 26, 2018) seeks to make drugs more affordable. CMS states:
[CMS] is committed to implementing President Trump’s blueprint to lower drug costs and reduce out-of-pocket costs for patients. In line with the policies discussed in the President’s blueprint, CMS issued a proposed rule… that would remove administrative hurdles to offer lower cost options to seniors and provide support for private sector partners by providing them the tools to lower the cost of prescription drugs.
Some of the most notable aspects of this proposal include allowing MAPD plans to actively pursue discounts for six protected classes of drugs, implementing new standards for e-prescribing, and forcing greater drug pricing transparency.
Medicare Advantage and Part D Flexibility Proposed Rule (CMS-4185-P)
This rule (CMS-4185-P, proposed Oct. 26, 2018) seeks to make Part D plans more flexible. CMS states:
In addition to creating opportunities for increasing plan flexibility and plan choices, CMS is… taking steps to help the agency recover improper payments made to Medicare Advantage organizations. If finalized, the proposed changes would result in an estimated $4.5 billion savings to the Medicare Trust Funds over ten years, largely arising from recovery of overpayments to MA plans.
Among other things, the most relevant features of this rule include expanded access to telehealth services and, even more importantly for MAPD plans, several star ratings changes for the 2022 rating year. CMS considers these star ratings changes ones that will “improve the stability and predictability” of cut points for plans by effectively instituting “guardrails” to prevent dramatic cut point hikes (such as those we saw this year). Other proposals include shifts in the cut point methodology to mitigate outlier impacts and more adjustment mechanisms for “extreme and uncontrollable circumstances.”
Thinking Ahead for MAPD Plan Quality Measure Strategies
The benefits of lowering drug costs are obvious for plans and members alike. Expanded access to telehealth services, however, opens an untapped source of influence for MAPD plans, impacting everything from preventive care to pharmacy services and intervention capabilities. The primary hurdle for plans under these proposed rules is not a new one – it’s the problem of scale. MAPD plans will need to develop scalable solutions and more efficient administrative processes to prepare for (and benefit from) these changes.
Your Voice Counts: Comment on CMS’s Proposed Rules
RxAnte fully intends to make comments on these proposed rules (follow us on LinkedIn or Twitter for updates). The deadline for CMS-4180-P is January 25, 2019, and the deadline for CMS-4185-P is December 31, 2018. We encourage our clients and others in the healthcare community to submit their comments as well:
- Submit comments on CMS-4180-P: https://www.regulations.gov/comment?D=CMS-2018-0149-0002
- Submit comments on CMS-4185-P: https://www.regulations.gov/comment?D=CMS-2018-0133-0001