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 CMS Proposes Expanding MA Program Via Kidney Failure, Telehealth Options

Proposed changes offered by the Centers for Medicare & Medicaid Services (CMS) to the Medicare Advantage (MA) and Part D (PD) prescription drug programs are aimed at reducing beneficiary cost sharing for drugs and to give those with late-stage kidney disease more coverage options, the agency said.

Annual changes are routine for the MA and PD programs and come at a time of increasing activity among long term and post-acute care providers in offering MA plans to residents.

The Calendar Year 2021/2022 Medicare Advantage and Part D Proposed Rule (CMS-4190-P) would require Part D plans to offer real-time drug price comparison tools to beneficiaries starting Jan. 1, 2022, so consumers could shop for lower-cost alternative therapies under their prescription drug benefit plan.

CMS said beneficiaries, for example, would be able to compare drug prices at the doctor’s office to find the most cost-effective prescription drugs. Additionally, if a doctor recommends a specific cholesterol-lowering drug, the patient could easily look up what the copay would be and see if a different option might save the patient money.

Further on the drug front, in the Medicare Part D program, beneficiaries choose the prescription drug plan that best meets their needs. Many plans offering prescription drug coverage place drugs into different “tiers” on their formularies.

CMS said while all drugs on a plan’s specialty highest-cost tier have the same level of cost sharing, the proposed rule would allow a second, “preferred” specialty tier in Part D with a lower cost-sharing amount.

“This proposal is designed to give Part D plans more tools to lower out-of-pocket costs for enrollees. Plans would be able to demand a better deal from manufacturers of the highest-cost drugs in exchange for placing their products on the ‘preferred’ specialty tier,” CMS said.

For MA plans, the new proposals focus on kidney disease, specifically those beneficiaries with End-Stage Renal Disease (ESRD), or kidney failure, who are only allowed to enroll in MA plans in limited circumstances.

“Today’s proposed rule implements the 21st Century Cures Act requirements to give all beneficiaries with ESRD the option to enroll in a Medicare Advantage plan starting in 2021. This will give patients with ESRD access to more affordable Medicare coverage choices and extra benefits such as transportation or home-delivered meals,” CMS said.

Also, under the proposal MA beneficiaries would be able to access additional telehealth benefits not offered under Medicare fee-for-service, giving patients the option to receive health care services from their homes.

“CMS is proposing to build on the current benefits and give MA plans more flexibility to count telehealth providers in certain specialty areas like psychiatry, neurology, or cardiology toward network adequacy standards, which would encourage greater use of telehealth services as well as increase plan choices for beneficiaries,” the agency said.

The proposed changes would give seniors more plan choices in rural areas, increase competition between plans, and allow providers to take advantage of the latest technologies, CMS said.

A fact sheet on the CY 2021/2022 Medicare Advantage and Part D Proposed Rule (CMS- 4190-P) is at: www.cms.gov/newsroom/fact-sheets/contract-year-2021-and-2022-medicare-advantage-and-part-d-proposed-rule-cms-4190-p-1.

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