CMS 2023 Final Rule: Top 5 Takeaways



The Centers for Medicare and Medicaid Services (CMS) published a preliminary Final Rule on April 29 revising Medicare Advantage (MA) program and Part D program regulations to implement changes related to marketing and communications, past performance, Star Ratings, network adequacy, medical loss ratio reporting, special requirements during disasters or public emergencies, and pharmacy price concessions. The following are some of the most significant changes MA plans and Dual eligible Special Needs Plans (D-SNP) should pay close attention to.


Strategy to Advance Health Equity

CMS’ Final Rule notably continues the trend of the Biden Administration to advance health equity and to utilize dual-eligible status as a social determinant for health risk and outcomes.


For these enrollees, the new rule requires plans to:

  • Annually assess social risks across the domains of housing stability, food security, and access to transportation;

  • Deliver enrollee centered care intended to improve outcomes;

  • Offer free language interpreter services; and,

  • Require all D-SNPs establish and maintain one or more enrollee advisory committees for each state in which the D-SNP is offered and consult with advisory committees on ways to improve health equity for underserved population.


Maximum Out of Pocket (MOOP)

Currently, MA plans must establish a limit on beneficiary cost-sharing for Parts A and B services. Upon reaching that limit, plans must pays100% of service costs. For these calculations, plans only count enrollee contributions towards MOOP limits, rather than the total amounts owed by a beneficiary for their cost-share. This results in secondary payor payments not being counted towards beneficiary MOOP and results in effectively no limit on the how much state programs, like Medicaid, pay for a dually eligible beneficiary’s cost-sharing. The final rule revises MOOP such that the limit (after which the plan pays 100% of MA costs) is calculated based on the sum of all Medicare cost-sharing in the plan benefit, whether that Medicare cost-sharing is paid by the beneficiary, Medicaid, or other secondary insurance.


Increased Marketing Oversight

In addition to health equity advancements, and consistent with previously issued guidance, CMS is strengthening oversight of third-party marketing organizations to detect and prevent the use of confusing or potentially misleading activities to enroll beneficiaries in plans, reinstate the inclusion of a multi-language insert in all required documents, codify ID card standards and more.


Reducing Pharmacy Costs

CMS is redefining “negotiated price” as the baseline, or lowest possible, payment to a pharmacy and requiring plans to apply all price concessions they receive from network pharmacies to the negotiated price at the point of sale, so that beneficiaries can receive shared savings.


Network Adequacy

CMS is now requiring MA applicants demonstrate a sufficient network of contracted providers to care for beneficiaries before CMS will approve an application for a new or expanded MA contract. CMS will allow applicants a 10-percentage point credit toward the percentage of beneficiaries residing within time and distance standards and will allow plan applicants to use Letters of Intent in lieu of signed provider contracts at the time of application and CMS’ review, but effective January 1 of every year, organizations must be in full compliance (the 10% credit use of LOIs will no longer apply).


The ongoing focus needed to deliver personalized support and care to even the most complex beneficiaries will be a priority to health plans as they roll out their strategies from the Final Notice. Our distinguished team of experts collaborated to provide an in-depth analysis of the 613-page final regulation. Click here to download.


Unsure where to start? Our team has a strategic path based on the final rule and what health plans should be thinking and planning for 2022 and beyond. Contact us TODAY to get started.


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