On April 4, 2024, CMS announced a final rule implementing certain policy changes to the Medicare Advantage (MA) program (Medicare Part C) and the Medicare Prescription Drug Benefit program (Medicare Part D). “Changes in this final rule strengthen protections and guardrails, promote healthy competition, and ensure that Medicare Advantage and Part D plans best serve enrollees' needs,” according to a fact sheet accompanying the rule. It builds on existing Biden-Harris administration policies to ensure that Specific policy changes include revising agent and broker compensation rules to discourage anti-competitive operations, restricting the dissemination of beneficiary data by third-party marketing organizations (TPMOs), and increasing the integrity of conduct. Includes improved access and changes to configuration and requirements. Changes to the rules for establishing the Utilization Management Committee will come into effect on June 3, 2024.
Agent and Broker Compensation Guardrails
The final rule updates CMS's existing regulations governing the compensation that agents and brokers can receive when enrolling Medicare beneficiaries in MA and prescription drug plans (PDPs). Existing regulations limit the compensation a broker and agent can receive from his MA and PDP plans, but provide uncapped additional payments to plans to cover administrative costs such as training and operating expenses. is permitted to do so. CMS has observed that MA and PDP plans offer bonuses and benefits framed as administrative add-ons (i.e., golf parties, travel, extra cash) in exchange for meeting enrollment goals . This practice is anti-competitive in the opinion of the agent and risks compromising the impartiality of agents and brokers. The final rule closes this perceived loophole by incorporating administrative costs into the coverage limits.
The final rule also prohibits CMS from entering into plans with agents or brokers that would be considered anticompetitive agreements. The new regulations specifically require that plans and agents or intermediaries that may “directly or indirectly interfere with the agent or broker's ability to objectively evaluate and recommend the plan that best meets the health care needs of a beneficiary” Prohibits the terms of the contract between.
Restrictions on distribution of beneficiary data by third party marketing organizations
CMS requires third-party marketing organizations (TPMOs) (entities, including agents and brokers, who are compensated for promoting enrollment in MA or PDP plans) to distribute beneficiary contact information to other TPMOs. We have observed that in some cases they are sold. This information is typically collected at the time a beneficiary initiates contact with her TPMO regarding potential enrollment in the plan. As CMS explains in the final rule, some TPMOs may “not disclose personal contact information to other entities through ready-to-read disclaimers or very small font web- or print-based disclaimers.” ” CMS proposed to categorically prohibit TPMOs from selling beneficiary contact information. However, the final rule allows TPMOs to sell a beneficiary's contact information if the TPMO has the beneficiary's express written consent.
Annual Health Equity Analysis of Utilization Management Policies and Procedures
Existing CMS regulations require MA plans to review and approve all UM policies and procedures at least annually to ensure consistency with traditional Medicare national and local coverage determinations and related Medicare legislation. Establishment of a Usage Management (UM) Committee is required. The final rule amends these rules and provides that at least one member of the UM committee must have expertise in health equity. The final rule also requires the UM Commission to annually conduct a health equity analysis of the preauthorization policies and procedures used by MA plans. MA plans are required to publish their analysis results on their website.
Improving access to behavioral health providers
CMS is changing regulations governing network adequacy standards for MA plans. Under the new regulations, the suitability assessment will take into account the number of “outpatient behavioral therapy” providers and facilities participating in the network. This includes marriage and family therapists, mental health counselors, opioid treatment programs, community mental health centers, and other behavioral health and addiction medicine professionals and facilities.
Notification of additional benefits available for mid-year enrollees
Most MA plans offer standard Medicare benefits plus additional benefits such as vision, hearing, fitness, and dental. These benefits are subsidized by the government through rebates and aim to address social determinants of unmet health needs, such as food insecurity and lack of access to transportation. MA plans have reported low enrollment rates of these additional benefits in recent years. To address this, the final rule requires an MA plan to issue a notice to an enrollee who has not taken advantage of any supplemental benefits available to him by June 30 of the year.
A copy of the final rule is available here and a CMS press release regarding this rule is available here.
