The Centers for Medicare and Medicaid Services recommended modifications that will lower prescription drug prices for Medicare Advantage and Medicare Part D beneficiaries.
These improvements aim to raise affordability, improve care coordination, and address health inequities for seniors and people with disabilities, all while requiring greater insurer accountability.
“We continue to hear from Medicare Advantage enrollees who are having difficulty accessing the care they require and are entitled to, and CMS remains committed to removing these barriers,” said Dr. Meena Seshamani, CMS deputy administrator and head of the Center for Medicare.
Seshamani stated that no senior or person with disabilities on Medicare should have difficulty navigating alternatives, affording doctor-prescribed medications, or accessing necessary inpatient or rehabilitation treatment.
The proposed regulation includes policies that remove obstacles to care caused by prior authorization and ensure safeguards for the use of artificial intelligence to protect access to health services while increasing access to behavioral health care providers.
“Our loved ones on Medicare need treatment that prioritizes their needs. In a news release, Health and Human Services Secretary Xavier Becerra proposed improving openness, accountability, and consumer safeguards in Medicare Advantage and Part D plans to ensure that everyone receives high-quality care.
He went on, “To accomplish this, we aim to remove obstacles that delay care or deny people the services and medications they require to stay healthy. In addition, we continue to encourage competition among pharmacies and other healthcare enterprises.
The shift will reduce out-of-pocket costs for weight reduction medications such as Wegovy, Ozempic, and Mounjaro, among others, which can cost up to $1,000 per month and are only reimbursed when used to treat disorders like diabetes.
CMS proposes to “reinterpret” the Act that currently bans anti-obesity drugs for the treatment of obesity for persons covered by Medicare Part D.
The CDC states that 40.3% of adults in the United States are obese.
According to CMS, the agency “would continue to exclude anti-obesity medications from Part D coverage when being used in individuals who are overweight but without obesity or another condition that is a medically accepted indication.”
However, because the proposal reinterprets the Medicaid Act, it would also affect the Medicaid program.
Medicare Advantage enhancements include improved payment accuracy through the update of the risk adjustment model and alignment with the current healthcare coding standard.
The suggestions focus on changes to streamline coverage while lowering out-of-pocket expenditures for prescription medications.
CMS proposed four improvements to reinforce current regulations:
- Clarify that the enrollee’s additional duty to pay for services cannot be determined until an MA organization decides on a payment request.
- Clarify that an MA organization makes a coverage determination when an enrollee receives inpatient or outpatient care.
- Strengthen the notice requirements for the MA organization’s decision.
- A modification in the reopening guidelines removes an MA organization’s option when revisiting an approved permission for an inpatient hospital admission.
