The Centers for Medicare & Medicaid Services (CMS) has issued a rule finalizing policies for contract year 2023 Medicare Advantage (MA) and Medicare prescription drug benefit programs.
The rule finalizes proposals on increased agency oversight of plan marketing, expansion and network adequacy, reinstatement of medical loss ratio reporting requirements, and equity-oriented changes to dual-eligible special needs plans (D-SNPs).
CMS will require MA applicants to demonstrate they have a sufficient network of contracted providers to care for beneficiaries before CMS will approve an application for a new or expanded MA contract. In addition, CMS reinstates previously rescinded medical loss ratio reporting requirements, requires reporting on amounts spent on supplemental benefits, and establishes that plans with a track record of poor performance may be disqualified from expanding their contracts or entering new ones.
CMS finalizes a requirement that all D-SNPs establish and maintain at least one enrollee advisory committee for each state in which the D-SNP is offered, and that D-SNPs must consult with the advisory committees on health equity and access issues. CMS finalizes a requirement that all health risk assessments for SNP enrollee include at least one question from a list of screening instruments specified by CMS on housing stability, food security, and access to transportation, but will not require that all SNPs use the same specific standardized questions.
The final rule also creates a mechanism through which states can require D-SNPs to use integrated materials to make it easier for beneficiaries to understand the full scope of Medicare and Medicaid benefits available. The agency finalizes a pathway to have star ratings reflect the D-SNP’s local performance, separating the D-SNP star ratings from the MA star ratings.
CMS specifies that the maximum out-of-pocket limit in an MA plan will be calculated based on all the Medicare cost-sharing in the plan benefit, regardless of the payer and regardless of whether the cost-sharing remains unpaid.
Additional details are available in a CMS fact sheet.