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CMS 4205-P Proposed Rule: Top Five Takeaways

Updated: Apr 3


On November 15, 2023, CMS issued a proposed rule that proposes revisions to regulations governing Medicare Advantage (MA or Part C), the Medicare Prescription Drug Benefit (Part D), Medicare cost plans and Programs of All-Inclusive Care for the Elderly (PACE), in Contract Year 2025 with a limited number of provisions to be applicable beginning with CY 2026. The proposed rule includes policies that would modify Star Ratings, marketing and communications guidance, agent/broker compensation, health equity policies, and dual eligible special needs plans (D–SNPs). Notable proposals also include agency attempts to improve access to behavioral health care via changes to network adequacy requirements, as well as increasing supplemental benefit utilization and appropriateness. Comments to the proposed rule are due January 5, 2024.


The following is just a small summary of notable takeaways from this proposed rule:


1. Improving Access to Behavioral Health

CMS has proposed updates to network adequacy standards in an effort to enhance behavioral health care services for plan enrollees through a new statutory category called “Outpatient Behavioral Health,” for services specific to marriage and family therapists (MFTs) and mental health counselors (MHCs) to include Medicare enrolled addiction or drug and alcohol counselors. In addition, CMS is proposing to add these providers to the list of the specialty types that will receive a 10% credit if the MAOs contracted network includes one or more telehealth providers of that specialty who provide additional telehealth benefits for covered services.


2. Utilization Management ‘Health Equity Analysis’

CMS is also proposing a new ‘health equity analysis’ that MAO’s must undertake to bring transparency to utilization management (UM) policies and procedures for enrollees who receive the Part D low-income subsidy, are dually eligible, or have a disability. These populations have been historically and disproportionately impacted and underserved with delays and denials of access to certain services, and the proposed rule aims to address this issue by requiring MAO’s to analyze their UM policies and procedures from a health equity perspective, and update the composition of, and responsibilities for, the UM committee to require:

  • A member of the UM committee to have expertise in health equity;

  • The UM committee must conduct an annual health equity analysis of prior authorization policies and procedures used by the Medicare Advantage plan organization; and,

  • MAOs must make the results of their analyses publicly available on their website.


Notably, CMS is soliciting specific comments on additional enrollee groups, items, or services that should be disaggregated for health equity review.


3. Mid-Year Enrollee Notification of Available Supplemental Benefits

In the proposed rule, CMS is making efforts to bring more visibility to offered supplemental benefits. Across the national landscape, MAO’s offer an average of 23 supplemental benefits, yet utilization remains low. To address this gap, CMS is proposing MAOs engage in “minimum outreach efforts” to educate enrollees about what is available to them. One education tactic being proposed is a “Mid-Year Enrollee Notification of Unused Supplemental Benefits,” which would be required to be personalized to enrollees, include a list of any benefits they have not accessed during the first six months of the year, and be issued on an annual basis. The notification would need to include:

  • The scope of the benefit and related cost-sharing;

  • Instructions on how to access the benefit;

  • Any application information for each available benefit; and,

  • A customer service number to call if additional help is needed.


4. Agent-Broker Compensation Restrictions

In an effort to address compensatory loopholes and ‘steering,’ CMS is proposing to redefine “compensation” to fixed amounts agents and brokers can be paid irrespective of an enrollee’s plan choice. To get there, CMS is expanding the regulatory definition of “compensation” to include ‘all activities associated with the sales to/enrollment of a beneficiary into a Medicare Advantage plan or Part D plan.’


Additionally, the proposed rule would limit certain contract terms between plans and field marketing organizations that result in provisions such as volume-based bonuses for enrollment into certain plans, as CMS perceives such tactics as interfering with agents or brokers properly assisting enrollees in finding plans best suited to their needs.


5. Expanding Dually Eligible Enrollees Qualifications and a new SEP

Increasing the percentage of dually eligible Medicare Advantage Plan enrollees who are in plans that also cover Medicaid would expand access to integrated materials, unified appeal processes across Medicare and Medicaid, and continued Medicare services during an appeal for those individuals. The proposed rule increases the percentage of dually eligible MAO enrollees by offering more opportunities for enrollment in plans that integrate Medicare and Medicaid and more opportunities to switch to Traditional Medicare, as opposed to Medicare Advantage, which differ from the enrollee’s Medicaid plan.


CMS’ effort to improve experiences for these populations of beneficiaries would include revisions to current special enrollment periods (SEP) for dually eligible and other Part D low-income subsidy enrolled individuals to once-per-month to enroll in a standalone prescription drug plan and create a new ‘Integrated Care’ SEP which would allow dually eligible individuals to elect an integrated dual eligible special needs plan (D-SNP) on a monthly basis.


Unsure where to start? Our team expects many of the proposals in this rule to be codified as final and has outlined a strategic path for optimized outcomes and what health plans should be thinking and planning for 2025 and beyond. Contact us today to get started.


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