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Final Rule Makes Important Changes to Medicare Advantage and Part D

This week, the Centers for Medicare & Medicaid Services (CMS) finalized proposed policy changes to Medicare Advantage (MA) and Part D that may improve equity, access to care, and information for people with Medicare.

At Medicare Rights, our comments were largely supportive, and we are glad to see so many of our priorities and recommendations reflected in the final rule. This includes policies to expand and improve equity in MA by adding more explicit language around cultural competence; requiring more information about cultural and linguistic capabilities in provider directories; establishing a health equity index to further incentivize MA and Part D plans to improve care for disadvantaged populations; building in support for people with low digital health literacy to improve access to telehealth; and requiring that MA organizations’ quality improvement programs include efforts to reduce disparities. 

For behavioral health, the rule changes include adding new provider types—Clinical Psychologists and Licensed Clinical Social Workers—and creating network adequacy standards for them. In addition, the rule improves access standards by clarifying that prior authorization cannot be used for behavioral health in emergency situations and by establishing wait time standards for behavioral health to meet network adequacy needs.

The rule made important changes to prior authorization more broadly by clarifying that MA plans may not deny coverage for services that are covered by Original Medicare, though it may use some processes to determine medical necessity. In addition, the rule should increase public information about a plan’s prior authorization procedures and rationales, though it is unclear if this will be at a level beneficiaries will be able to use when choosing a plan.

We also appreciate the stronger marketing rules, in particular for television ads. Though we are disappointed that third parties and brokers will still be able to collect contact information from potential enrollees, the rule will require these agents to disclose information about the plans they are selling or marketing. Marketers will also have additional restrictions on how, when, and where they can contact or solicit enrollees.

Getting information will also be easier for people who require translated or accessible format materials. Currently, people may have to ask for these materials each time, but the new rule will treat a request as a standing order, allowing future materials to be delivered to them in the requested formats.

Importantly, the rule implements recent low-income program modifications. It effectuates the aspects of the Inflation Reduction Act which expand access to Extra Help, the low-income subsidy (LIS) that helps people pay for prescription drugs. It also makes permanent Medicare’s Limited Income Newly Eligible Transition (LI NET) Program, which provides transitional prescription drug coverage to those who need it. These critical assistance pathways will help more beneficiaries afford coverage and care.

We applaud these changes and will continue to work with CMS, the rest of the Biden-Harris administration, and lawmakers to improve the affordability of Medicare for current and future beneficiaries.

Read our comments on the proposed rule.

Read the final rule and fact sheet.

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