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CMS proposes new Medicare Advantage Star Ratings, marketing rules

The Centers for Medicare and Medicaid Services is considering significant changes to how Medicare Advantage quality is measured, how provider networks are assembled and how insurance companies market their products.

In a draft regulation published Wednesday, CMS proposes a variety of changes to Medicare Advantage for next year, including modifications to the Star Ratings bonus payment program, which the agency projects would save nearly $25 billion over 10 years.

CMS wants to eliminate the “reward factor” that gives higher annual ratings to carriers that consistently perform well over time. In its place, CMS aims to establish a health equity index that would encourage Medicare Advantage insurers to identify beneficiaries who have disabilities, receive low-income subsidies or are dually eligible for Medicare and Medicaid, and create programs to improve health outcomes for them.

In addition, CMS proposes reducing the weight of patient experience and complaints when calculating the ratings. The agency doubled the effect of those metrics this year, which insurance companies say contributed to an industrywide drop in scores.

The regulator also is taking aim at marketing practices that have attracted negative attention. The number of consumer “marketing misconduct” complaints surged to more than 39,600 last year, a 157% increase from 2020, according to federal data CMS provided to Modern Healthcare. Marketers argue the number of complaints is small relative to the 29.5 million people with Medicare Advantage.

The agency expects the complying with these marketing rules would require a one-time, $172,000 expense per insurer.

As part of President Joe Biden’s broader mental health agenda, CMS proposes strengthening Medicare Advantage provider networks by adding clinical psychologists, licensed clinical social workers and prescribers of opioid use disorder medications to the list of specialists used for network adequacy reviews. The agency also would require Medicare Advantage insurers to notify enrollees when behavioral health or primary care providers exit their networks during a plan year. On Monday, CMS issued a separate proposed rule that would require health insurance exchange plans to include more mental health and substance use disorder treatment providers in their networks.

The Medicare Advantage regulation also addresses prior authorizations, the subject of another proposed rule issued this month. Previously approved prior authorizations would remain in force for the duration of a patient’s treatment under the rule published Wednesday. CMS also aims to eliminate prior authorization requirements for emergency behavioral healthcare.

The 2024 Policy and Technical Changes to the Medicare Advantage and Medicare Prescription Drug Benefit Programs proposed rule also includes provisions to:

  • Allow Medicare Part D prescription drug plans to immediately substitute biosimilars for interchangeable biologic drugs. Biosimilar competitors to Abbvie’s rheumatoid arthritis drug Humira, which is the highest-grossing pharmaceutical of all time, will hit the market for the first time in 2023.
  • Expand the availability of full-benefits coverage for Medicare Part D low-income subsidies to beneficiaries earning up to 150% of the federal poverty level, which is $20,385 a year for a single person. Congress enhanced the subsidies available through the Inflation Reduction Act, which Biden enacted in August.

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