- Medicare Part D enrollees would be able to check their drug benefits in real time beginning in 2022, allowing them to see the co-pays required for certain prescription drugs and any alternatives that may be less expensive, under a proposed rule CMS released Wednesday.
- Also, Part D plans would be able to carve out a second tier for high-cost specialty drugs that now all occupy the same tier. A second tier would result in lower costs for patients, CMS said, by generating greater pricing concession from drug manufacturers who want to be on the "preferred" second tier.
- The proposed rule would also allow patients with end-stage renal disease to enroll in Medicare Advantage plans starting in 2021. Payer groups, however, voiced concerns about that change.
President Donald Trump's administration has tried to inject more transparency and competition into the healthcare landscape and Wednesday's proposed policies in the Advance Notice Part II seek to expand those efforts.
The MA market is an important facet of the healthcare sector for insurers and seniors. Payers view it as a major growth area compared to their commercial markets as more seniors choose privately managed MA plans over traditional Medicare. MA plans attracted 23 million members for 2020, CMS Administrator Seema Verma told reporters Wednesday.
CMS argues the new proposals are designed to give plans more tools and flexibility to foster greater competition.
But America's Health Insurance Plans and the Better Medicare Alliance raised an alarm Wednesday on the proposed ESRD changes. AHIP said it is "concerned that some proposals could undermine the critical funding that protects millions of Americans' access to the benefits and care they need, including individuals with kidney disease who are newly eligible to enroll in Medicare Advantage."
BMA pointed to an Avalare analysis that found payment to MA plans for ESRD patients in highly-populated areas "may be significantly below actual patient costs."
Another part of the rule requires Part D plans to share how they evaluate and measure pharmacy performance in their networks. It will help inform the agency in its goal of creating a set of pharmacy performance measures.
CMS is also seeking public input on factoring Part D star ratings on utilization rates of lower-priced generics and biosimilars, essentially rewarding plans for higher adoption of lower-priced generics.
The agency also proposed a change to the methodology used to pay MA and Part D plans. The final rate announcement will be published by April 6. CMS said the change is expected to increase plan revenue by 0.93% on average.