Medicare Advantage Policy and Technical Changes for Contract Year 2019

December 2017 ~

On November 16th, CMS released its proposed contract year 2019 Medicare Advantage and Part D regulations intended to make major changes to the Medicare Advantage (MA) and Medicare Prescription Drug Benefit Programs. In the rule, CMS proposes a number of changes aimed at increasing transparency and alleviating administrative burdens on MA organizations and Part D sponsors.

The proposed rule focuses on many issues including but not limited to:

  • Implementing certain parts of the Comprehensive Addiction and Recovery Act of 2016, aimed at establishing additional methods that Part D plans can use to reduce abuse or misuse of frequently abused drugs.
  • Codify the existing Star Ratings System for the MA and Part D programs with some changes including more clearly delineating the rules for adding, updating, and removing measures and modifying how CMS calculate Star Ratings for contracts that consolidate.
  • Reduce the burden of the compliance program training requirements by, among other things, eliminating the mandatory training for first tier, downstream and related entities.
  • Create a framework under which Part D plan sponsors may establish a drug management program for beneficiaries at risk for prescription drug abuse or misuse, and limit these beneficiaries’ access to coverage of “frequently abused drugs” to a selected prescriber(s) and/or network pharmacy(ies).
  • Clarify the Part D any willing pharmacy requirement to ensure that plan sponsors can continue to develop and maintain preferred networks while fully complying with the AWP requirement and not use standard terms and conditions to avoid compliance.
  • Establish “preclusion lists” under Medicare Advantage and Part D and prohibit sponsors from providing coverage for drugs prescribed by or items and services furnished by providers on such lists.
  • Allow MAOs and Part D sponsors to include the full amount of expenses for all fraud reduction activities—including fraud prevention, detection, and recovery—as a quality improvement activity (in the numerator) when calculating the medical loss ratio.

The proposed rule was published in the Federal Register on November 28th and can be seen here.



Source(s): CMS Quarterly Provider Update-Regulations; Federal Register; CMS Fact Sheet; Lexology;