The changes finalized today are generally effective for the 2022 plan year and will potentially lower enrollee cost sharing on some of the most expensive prescription drugs. The hallmark feature of the final rule will allow enrollees to know in advance and compare their out-of-pocket payments for different prescription drugs. There are many important changes for providers, pharmacies, and health plans as well. Here are some of the most important features of the final rule:
Rate Announcement and Changes
For complete information, please see the Fact Sheet from CMS.
Permitting a Second, “Preferred,” Specialty Tier in Part D
Under the final rule, beginning January 1, 2022, CMS is allowing Part D plans to have a second, “preferred” specialty tier with a lower cost sharing amount than their other specialty tier. This change is designed to give Part D plans more tools to negotiate better deals with manufacturers and lower out-of-pocket costs for enrollees in exchange for placing those products on the “preferred” specialty tier.
Medicare Advantage (MA) and Part D Prescription Drug Program Quality Rating System
This final rule codifies routine updates to the Star Ratings, including measure updates, technical clarifications regarding the calculation of scores for contracts that consolidate and for the extreme and uncontrollable circumstances policy when a measure score has a data integrity issue, and Quality Bonus Payment (QBP) rating rules for new contracts under existing parent organizations.
Establishing Pharmacy Performance Measures Reporting Requirements
Starting January 1, 2022, CMS is requiring Part D plans to disclose pharmacy performance measures to CMS, which will enable CMS to better understand how such measures are applied. CMS will also be able to report pharmacy performance measures publicly to increase transparency on the process and to inform the industry in its new efforts to develop a standard set of pharmacy performance measures.
Implementing Several Opioid Provisions of the SUPPORT Act
The final rule implements several provisions of the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act that require Part D plans to educate beneficiaries on opioid risks, alternate pain treatments, and safe disposal of prescription drugs that are controlled substances, including opioids. The final rule also expands drug management programs, through which Part D plans review with providers opioid utilization trends that may put beneficiaries at-risk, and medication therapy management programs, through which Part D plans provide beneficiary-centric interventions. The final rule also implements new requirements for Medicare Part D plan sponsors to report certain payment suspensions taken based on credible allegations of fraud against pharmacies when they are based on the SUPPORT Act authority (rather than previously existing bases such as contracts). It also implements new requirements that MA and Part D plan sponsors (including MA organizations offering MA-PD plans) report certain information related to inappropriate prescribing of opioids and any plan corrective actions to CMS via a secure internet portal.
Changes to the Programs of All-Inclusive Care for the Elderly (PACE)
CMS is finalizing a number of provisions that will reduce the administrative burden for PACE organizations related to the service determination request process and improve participants’ care and experience, including the participant appeals process and participant rights, and strengthen requirements related to the provision of services and record keeping.