CMS introduces significant policy updates in the first half of 2023, including drug price transparency, national care standards, expanded ACA plans, streamlined prior authorizations, changes to Medicare Advantage risk adjustment, drug price negotiation under Medicare, and stricter audits for Medicare Advantage plans. These policies aim to enhance transparency, improve care quality, and address pricing concerns within the healthcare system.
CMS makes notable policy changes in the first half of 2023, focusing on areas such as drug price transparency, care standards, ACA plans, prior authorizations, Medicare Advantage risk adjustment, drug price negotiation, and audits. These updates aim to improve transparency, quality of care, and affordability within the healthcare industry.
1. Enhancing Drug Price Transparency: CMS proposes a new Medicaid rule requiring drug manufacturers, PBMs, and managed care plans to increase transparency by disclosing pricing information and details. Comments on the proposal are open until July 25.
2. Establishing National Standards: CMS proposes rules to set national care standards for fee-for-service Medicaid/CHIP and managed care plans, along with mandating online disclosure of provider payment rates by Medicaid managed care plans. Comments are open until July 3.
3. Expanded Nonstandard ACA Plans: CMS increases the cap on nonstandard plans offered by payers in each region from two to four while implementing new enrollment periods and stricter network requirements.
4. Streamlining Prior Authorization: A final rule by CMS streamlines Medicare Advantage and Part D prior authorization processes, emphasizing medical necessity confirmation and clamping down on misleading marketing practices.
5. Changes to Medicare Advantage Risk Adjustment: CMS proceeds with changes to Medicare Advantage risk adjustment, transitioning from ICD-9 to ICD-10 coding and modifying the Hierarchical Condition Categories model over three years.
6. Implementation of Medicare Drug Price Negotiation: CMS provides additional details and a timeline for the first-ever drug price negotiation process under Medicare, set to apply in 2026. The updated guidance will be published in the summer of 2023.
7. Stricter Audits for Medicare Advantage Plans: CMS implements stricter audits, eliminating the fee-for-service adjuster from risk adjustment data validation audits. This move may hold payers accountable for significant repayments to the federal government.
These seven key policies reflect CMS’s efforts in the first half of 2023 to address drug pricing transparency, national care standards, nonstandard ACA plans, prior authorization processes, risk adjustment changes, drug price negotiation under Medicare, and Medicare Advantage plan audits.
