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Proposed MA/Part D Changes for 2025 — Part II

by Yvonne Tso, PharmD, MBA




This article is the second in a series that highlights proposed changes for 2025 by the Centers for Medicare & Medicaid Services (CMS) in Proposed Rule 4205-P that would revise the Medicare Advantage Program (MA), Medicare Prescription Drug Benefit Program (Part D), Medicare Cost Plan Program, Programs of All-Inclusive Care for the Elderly (PACE), and Health Information Technology Standards and Implementation Specifications. A previous article on some of the major provisions in the Proposed Rules can be viewed here: https://www.integritasmedicare.com/post/proposed-ma-part-d-changes-for-2025-part-i.  There are twelve major provisions[1] in the Proposed Rule published on November 6, 2023. CMS is inviting comments on the proposed rules by 5pm January 5, 2024.

 

  • One of the major proposals is the curtailment of D-SNP[2] lookalike plans from 80% to 70% in 2025 and to 60% in 2026 by changing contracting standards. The motivation behind this change is the expansion of enrollment of dually eligible (Medicare-Medicaid) beneficiaries in D-SNP lookalike plans without meeting the requirements for a D-SNP, such as contracting with the state Medicaid agency describing key coordination and alignment responsibilities, submitting a Model of Care (which requires care coordination and management for the enrollees) to CMS for approval and oversight by CMS and charging a beneficiary premium for Part D, a high deductible for Part D drugs and the highest out-of-pocket limit on Part A and B services allowed by CMS[3]. CMS intends to require these lookalike plans to meet integration standards, at a minimum, by contracting limitations.[4]

 

  • Currently, beneficiaries enrolled in traditional Medicare and Medicare Advantage (MA) plans have the right to a fast-track appeal by an Independent Review Entity (IRE) when their covered skilled nursing facility (SNF), home health (HHA), or comprehensive outpatient rehabilitation facility (CORF) services are being terminated. Quality Improvement Organizations (QIOs) act as the IRE and conduct these reviews. Enrollees must request an immediate review by telephone or in writing by noon of the day before the effective date on the Notice of Medicare Non-Coverage (NOMNC). If, due to an emergency, the IRE is closed and unable to accept the enrollee's request for a fast-track appeal, the enrollee must file a request by noon of the next day that the IRE is open for business. If the enrollee misses the timeframe, the enrollee may request an expedited appeal from the plan.[5]

 

CMS is proposing to (1) require the QIO, instead of the MA plan, to review untimely fast-track appeals of an MA Plan’s decision to terminate services in a SNF, CORF and HHA and (2) eliminate the requirement that an enrollee has to give up the right to appeal a termination of services decision upon leaving the facility.[6] These provisions are available to beneficiaries in traditional Medicare.

 

  • When an MA plan decides to appeal the results of a risk adjustment data validation (RADV) audit, the plan goes through a three-level process: a) written request to appeal; b) hearing officer re-consideration; and c) CMS Administrator review. CMS is proposing to simplify the appeal process by requiring MA plans to exhaust all three levels of appeal for medical record review determinations before beginning the payment error calculation appeals process. In this way, adjudication of medical record review determinations is final before a recalculation of the payment error is completed and subject to appeal. [7]

 

  • CMS is soliciting comments on the feasibility of implementing multiple telecommunication standards for the Part D program simultaneously as of January 1, 2027. These are:

 

NCPDP (National Council for Prescription Drug Programs) SCRIPT[8] standard version 2023011 for electronic prescribing, ePA (electronic prior authorization) and medication history for which use of the NCPDP SCRIPT standard is mandatory

 

NCPDP RTPB (real time prescription benefit) standard version 13 - developed to enable the real-time exchange of patient-specific formulary and benefit information between providers/prescribers and pharmacy benefit managers (PBMs)/processors. Each RTPB transaction (request and response) is designed to provide an estimate of the patient’s out of pocket costs. The response to the provider contains patient’s eligibility, preferred pharmacy’s network status, the submitted product’s formulary status, coverage restrictions and estimated financial responsibility for the patient. Alternative products and pharmacies’ information are also provided.[9]

 

NCPDP Formulary & Benefit (F&B) standard version 60 – transmits data on the formulary status of drugs, preferred alternatives, coverage restrictions, and cost sharing based on the benefit design. The NCPDP F&B standard serves as a foundation for other electronic prescribing functions including ePA, real-time benefit check, and specialty medication eligibility when used in conjunction with other standards.[10]

 

The above proposals are intended to enhance the prescription drug program for all stakeholders. Part D sponsors would likely rely on their PBMs to comment on the feasibility of implementation for January 1, 2027. However, Part D sponsors also need to work with their PBMs to decide what proprietary information can be shared and be available via electronic transmission. Part D sponsors’ information technology (IT) team should be made aware of what is coming down the pike and how to prepare for it. The team may consider commenting on the proposed rule. January 1, 2027 may be 25 months away but the implementation process is a multidisciplinary collaboration. If there are concerns about the simultaneous implementation, this is the time to submit comments to CMS.

 

There are additional provisions within the proposed rule that aim to:

  • Increase the percentage of dually eligible managed care enrollees who receive integrated Medicare and Medicaid services 

  • Limit out-of-network cost sharing for D-SNP PPOs

  • Amend Part C and D reporting requirements

 

If you would like to discuss any of the above in preparation for submitting comments to CMS, please contact us at 415-596-5277 or info@integritasmedicare.com.  Integritas will continue to highlight other proposed changes in subsequent blog posts. Please follow us on https://www.integritasmedicare.com/blog.


[1] The proposed rule has 12 major provisions. There are additional revisions to the program in the proposed rules.

[2] D-SNP = Dual Eligible Special Needs Plan

[3] These high costs are shielded by cost-sharing assistance through the Medicare Savings Programs and Low Income Subsidy (LIS) and enrollees are protected from improper billing

[4] CY 2025 CMS Proposed Rule Fact Sheet, November 6, 2023

[5] Section 100.2 Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance August 2022

[6] CY 2025 CMS Proposed Rule Fact Sheet, November 6, 2023

[7] Proposed Rules 2023-24118

[8] SCRIPT = electronic prescribing standard

[9] Letter to the CMS Administrator re: Adoption of NCPDP Real-Time Prescription Benefit Standard Version 12 in 42 CFR § 423.160 Standards for Electronic Prescribing (b) Standards (7) Real-Time Benefit Tools and NCPDP Formulary and Benefit Standard Version 53 in 42 CFR § 423.160 Standards for Electronic Prescribing (b) Standards (5) Formulary and Benefits, August 20, 2021

[10] Proposed Rules 2023-24118

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