CMS recommends new Medicare Advantage Star Rating, marketing rules

The Centers for Medicare and Medicaid Services is looking at important changes to the way Medicare Advantage quality is measured, how provider networks are assembled, and how insurers market their products.

In a draft regulation released Wednesday, CMS proposes a variety of changes to Medicare Advantage for next year, including amendments to its Star Rating bonus payment program, which the agency expects will save nearly $25 billion over 10 years.

CMS wants to remove the “reward factor” that gives higher annual ratings to service providers that consistently perform well over time. health insurance to encourage Medicare Advantage insurers to identify beneficiaries who are disabled, receive low-income assistance or are eligible for Medicare and Medicaid, and create programs to improve outcomes health for them.

In addition, CMS recommends reducing the weight of patient experience and complaints when calculating ratings. The agency doubled the effect of those figures this year, which insurers say contributed to The whole industry dropped.

The regulator is also targeting marketing practices that have attracted negative attention. Number of consumers Complaints about “marketing misconduct” on the rise to more than 39,600 last year, up 157% from 2020, according to federal data CMS provided to Modern Healthcare. Marketers say the number of claims is small compared with the 29.5 million people with Medicare Advantage.

The agency expects compliance with these marketing rules to require a one-time cost, $172,000 per insurer.

As part of President Joe Biden’s broader mental health agenda, CMS proposes to strengthen the Medicare Advantage provider network by adding clinical psychologists, social workers Licensed clinicians and opioid use disorder prescribers are on a list of experts used to assess network eligibility. The agency will also require Medicare Advantage insurers to notify enrollees when primary care or behavioral health providers leave their network during a plan year. . On Monday, CMS released a separate proposed rule that would require health insurance exchange plans to include more mental health and substance use disorder providers in their network.

The Medicare Advantage rules also address prior authorization, the subject of another proposed rule released this month. Previously approved prior authorizations will remain in effect for the duration of a patient’s treatment under the rule announced Wednesday. CMS also aims to eliminate prior authorization requirements for urgent behavioral health care.

The 2024 Policy and Technical changes to the proposed rule for the Medicare and Medicare Advantage Prescription Drug Benefit Plans also include provisions to:

  • Allows Medicare Part D prescription drug plans to immediately replace biosimilars with interchangeable biologics. Biologic competitor to Abbvie’s rheumatoid arthritis drug humorThe highest-grossing pharmaceutical of all time, will hit the market for the first time in 2023.
  • Extends full benefit coverage of low-income Medicare Part D benefits to beneficiaries earning up to 150% of the federal poverty level, which is $20,385 a year for one person. Conference increase subsidies available through the Inflation Reduction Act, which Biden enacted in August.


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