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Proposed Medicare Advantage and PACE Regulations Offer Additional Beneficiary Protections

On Nov. 6, 2023, the Centers for Medicare and Medicaid Services (CMS) posted a proposed rule that would revise the Medicare Advantage Program (MA), Medicare Prescription Drug Benefit Program (Part D), Programs of All-Inclusive Care for the Elderly (PACE), and certain health information technology standards. The proposed regulations are intended to strengthen beneficiary protections and ensure that MA plans meet the needs of beneficiaries. The proposed regulations include, among other items:

  • Limits on compensation of MA brokers and agents.
  • Network adequacy standards for behavioral health providers.
  • Minimum outreach efforts to make enrollees aware of the supplemental benefits available to them, including a “Mid-Year Enrollee Notification of Unused Supplemental Benefits” to be issued annually.
  • New requirements for MA plans to demonstrate that Special Supplemental Benefits for Chronically Ill (SSBCI) beneficiaries have a reasonable expectation of improving the health or overall function of chronically ill enrollees and are supported by research. In addition, the proposed regulations seek to reduce misleading marketing related to these benefits. 
  • An annual health equity analysis of utilization management (UM) policies and procedures to identify disproportionate impacts of UM policies on individuals who are dually eligible, eligible for the Part D low-income subsidy (LIS), or have a disability.
  • More opportunities for enrollment in plans that integrate Medicare and Medicaid and more opportunities to switch to Traditional Medicare, by revising the quarterly special enrollment period (SEP) for dually eligible and other Part D LIS-enrolled individuals to a once-per-month SEP to enroll in a stand-alone prescription drug plan and by creating a new integrated care SEP to allow dually eligible individuals to elect an integrated dual-eligible special needs plan (D-SNP) on a monthly basis.
  • Limits on out-of-network cost sharing for D-SNP preferred provider organizations (PPOs) for specified services beginning in 2026. 
  • Revisions to the MA plan risk adjustment data validation appeals process.
  • Codification of current guidance that PACE organizations address and resolve complaints in the CMS Complaints Tracking Module (CTM).

The proposed regulations will be officially published on Nov. 15, 2023, and comments are due on Jan. 5, 2024.

Contact: Karen Lipson, klipson@leadingageny.org