CHA News Article

CMS Proposes Changes to Medicare Advantage, Part D Prescription Drug Programs
Also expands Medicare Advantage Value-Based Insurance Design Model

Earlier this month, the Centers for Medicare & Medicaid Services (CMS) issued the attached proposed rule updating Medicare Advantage and the Part D prescription drug program for contract year 2019. Among the proposed changes, CMS would codify the current Quality Star Rating System for Medicare Advantage and Part D plans, eliminate the “meaningfully different” standard that Medicare Advantage organizations must meet if they offer multiple plans in the same county and change the open enrollment period to Jan. 1 through March 31.

CMS also solicits comments on how Part D plan sponsors — through their pharmacy benefit managers — negotiate drug price concessions from drug manufacturers, network pharmacies and other entities. Specifically, CMS is interested in learning if Part D plans and their pharmacy benefit managers are lowering premiums and cost-sharing for beneficiaries because of the savings generated from price concessions.

The proposed rule also implements certain provisions of the Comprehensive Addiction and Recovery Act and the 21st Century Cures Act to address the opioid epidemic. The Comprehensive Addiction and Recovery Act requires CMS, beginning in 2019, to establish a framework for Part D plan sponsors to implement drug management programs that limit “at risk” beneficiaries’ access to controlled substances. The rule proposes to designate opioids (with limited exceptions) as frequently abused drugs and tie the definition of an “at risk” beneficiary to the protocols in CMS’ current Part D Opioid Drug Utilization Review Policy Overutilization Monitoring System. Comments on the proposed rule are due Jan. 16.

In addition, CMS announced last week that it will expand the Medicare Advantage Value-Based Insurance Design Model to 15 new states, including California, beginning in 2019. This model allows Medicare Advantage plans to develop clinically nuanced benefit designs – including supplemental benefits or reduced cost sharing – to targeted groups of enrollees with certain chronic conditions, to improve health outcomes and reduce costs. Medicare Advantage organizations that wish to participate in 2019 must apply by Jan. 26. Additional information is available at