CMS Proposes Changes to MA, Part D Including Ability to Terminate Low Performers

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The Centers for Medicare & Medicaid Services Oct. 3 proposed changes to the 2013 Medicare Advantage and the Part D prescription drug plans programs, including allowing for the termination of poor performers and expanding drug coverage to benzodiazepines and barbiturates.

“We propose to give CMS the authority to terminate MAOs [Medicare Advantage organizations] and Part D sponsors that have failed to provide, over a course of 3-years, service meriting at least 3-star ratings,” the proposed rule said.

CMS rates plans on a five-star quality scale, and, under a demonstration program, offers bonuses to MA plans that rate at least three stars.

Similarly, CMS proposed to be allowed to deny applications submitted by MAOs and Part D sponsors that have performed poorly.

“Both these provisions, in our opinion, would give entities that want to administer benefits to Medicare beneficiaries a strong incentive to pay attention to the star rating criteria and provide for better quality health care if they wish to stay in or join the program,” CMS said.

In addition, “low-rated sponsors interfere with the efficient and effective administration of the MA and Part D programs as beneficiaries rely on us to ensure that the array of plan choices only includes offerings from sponsors that have demonstrated that they can provide at least good quality services to their members,” CMS said.

Industry Opposition

America's Health Insurance Plans, the major industry group, has opposed this policy and told CMS that it is inappropriate to terminate plans based on their star ratings.

“Utilizing quality improvement measures for compliance purposes and establishing penalties for failure to achieve benchmarks is antithetical to well-established quality improvement principles and undermines quality improvement processes,” AHIP told CMS earlier this year.

“While we recognize the importance of plan compliance with MA and Part D program requirements … we are concerned that use of the star rating system to determine program compliance is a fundamentally different purpose than many measures are designed to serve.”

The proposed rule would codify various provisions of the Patient Protection and Affordable Care Act (PPACA) and the Medicare Improvements for Patients and Providers Act (MIPPA).

Requirements under MIPPA would provide for beneficiaries with health conditions that require benzodiazepines and, as specified, barbiturates, the proposal said.

Prescriptions dispensed on or after Jan. 1, 2013, would have to cover barbiturates when used for treatment of epilepsy, cancer, or a chronic mental health disorder, as well as benzodiazepines.

SNP Flexibility

Among other provisions, the proposed rule would allow high-quality fully integrated dual eligible (FIDE) special needs plans (SNPs) to offer supplemental benefits beyond those currently allowed for MA plans, including nonskilled nursing activities and in-home food delivery.

PPACA required CMS to make Medicare and Medicaid work together more effectively to improve patient care and lower costs, the proposal said.

“We are interested in assessing whether certain supplemental benefits could help prevent health status decline in the dual eligible population, and reduce the quantity and cost of future health care needs,” the proposed rule said.

Another provision would require Part D sponsors submitting prescription drug event records to include prescribers' National Provider Identifiers (NPIs).

The proposed rule also would require pharmacy benefit managers to report additional financial information to improve data collection and tracking, help better identify the prescriber of Part D medications, and assist law enforcement in the conducting of investigations when there is suspected fraud associated with a prescription drug claim.

This rule is set for publication in the Oct. 11 Federal Register. Comments are due Dec. 12.

The rule is at .