Where Are the Cliff Notes for This?

[somarco]

226 pages of gobbly gook created and reviewed by dozens of lawyers who need to justify their government salary.

Perhaps our resident AI guru can run it through chatGPT and provide mere humans some insight.

https://www.govinfo.gov/content/pkg/FR-2023-04-12/pdf/2023-07115.pdf

 

[marindependent]

This Cliff's Notes?

 

[somarco]

This Cliff's Notes?

Quite possible . . . Cliffy retired from the USPS and now resides in Congress.

 

[kgmom219]

226 pages of gobbly gook created and reviewed by dozens of lawyers who need to justify their government salary.

Perhaps our resident AI guru can run it through chatGPT and provide mere humans some insight.

https://www.govinfo.gov/content/pkg/FR-2023-04-12/pdf/2023-07115.pdf

1. You don't care because its all MA or Part D crapola
2. The carriers are manipulating Risk Adjustment to make more money
3. Joe and JJ really screwed agents so there's a bunch more rules
4. MA now costs the taxpayer more than OM
5. You still don't care because its all MA or Part D crapola

 

[Duaine]

Here is a synopsis if the PDF:

Source URL
https://www.govinfo.gov/content/pkg/FR-2023-04-12/pdf/2023-07115.pdf

Summary
- The Centers for Medicare & Medicaid Services (CMS) has issued a final rule to revise regulations related to the Medicare Advantage (Part C), Medicare Prescription Drug Benefit (Part D), Medicare cost plan, and Programs of All-Inclusive Care for the Elderly (PACE) programs.

- The changes include updates to Star Ratings, marketing and communications, health equity, provider directories, coverage criteria, prior authorization, passive enrollment, network adequacy, and other programmatic areas.

- The rule also codifies regulations implementing section 118 of Division CC of the Consolidated Appropriations Act, 2021, section 11404 of the Inflation Reduction Act, and includes provisions that will codify existing sub-regulatory guidance in the Part C, Part D, and PACE programs.

- The effective date of the regulations is June 5, 2023, and the provisions are applicable to coverage beginning January 1, 2024, except as otherwise noted.

- The rule includes a health equity index (HEI) reward for the 2027 Star Ratings to incentivize Parts C and D plans to focus on improving care for enrollees with social risk factors (SRFs).

- CMS is also requiring MA organizations to develop and maintain procedures to identify and offer digital health education to enrollees with low digital health literacy to assist with accessing any medically necessary covered telehealth benefits.

- Finally, the rule includes several regulatory changes to address concerns regarding prior authorization, including clarifications of coverage criteria for basic benefits and use of prior authorization, additional continuity of care requirements, and annual review of utilization management tools.

- The CMS will monitor non-D-SNP plans for deceptive marketing practices and consider ways to ensure transparency and accountability in MA contracting and oversight.

- A new Part D special enrollment period (SEP) has been established for individuals who enroll in Part B during the Part B General Enrollment Period (GEP).

- The SEP for Individuals Who Enroll in Part B During the Part B GEP to request enrollment in a Part D plan has been finalized without modification.

- New exceptional condition SEPs for MA and Part D enrollment have been proposed to align with the new Medicare premium-Part A and B exceptional condition SEPs that CMS has finalized in 42 CFR 406.27 and 407.23.

- The text proposes regulations for the LI NET program, including eligibility requirements, enrollment processes, and beneficiary protections.

- LI NET would be available to all categories of individuals who are LIS-eligible, including full-benefit dual-eligible individuals, low-income subsidy (LIS) eligible individuals, and partial subsidy individuals.

- Individuals can be enrolled into LI NET through auto-enrollment, point-of-sale for immediate need individuals, direct reimbursement, and LI NET enrollment form.

- LI NET enrollment begins on the first day of the month an individual is identified as eligible and ends after 2 months.

- Immediate need individuals can provide documentation to the LI NET sponsor to confirm LIS eligibility and receive immediate access to covered Part D drugs at the point-of-sale.

- If an immediate need individual's LIS status cannot be confirmed within 2 months, that individual would not be automatically enrolled into a Part D plan.

- CMS proposed requirements for the LI NET sponsor, including a minimum of 2 years contracting with CMS as a Part D sponsor, technical and operational capabilities, and outreach plans.

- CMS enrolls over 90% of LI NET beneficiaries and expects to continue to be responsible for most enrollments in a permanent LI NET program.

- The LI NET sponsor must establish and manage a toll-free customer service line and adjudicate claims from out-of-network pharmacies.

- CMS proposed to follow a contracting approach to select the LI NET sponsor for the 2024 plan year and onwards, with selection criteria based on experience, pharmacy access, past performance, and ability to meet requirements.

- CMS would have the authority to impose intermediate sanctions if the LI NET sponsor violates its contract, and non-renewal would require ample notice and coordination with a successor LI NET sponsor for a seamless transition.

- The proposed rule establishes provisions for the Low Income Subsidy (LIS) Medicare Part D program, including appeals and overpayment requirements.

- Certain requirements related to dissemination of general information, formulary information, formulary requirements, and medication therapy management (MTM) program requirements do not apply to the LIS NET program.

- The proposed rule waives some of the cost control and quality improvement requirements in Part 423 Subpart D for the LI NET program.

- The proposed rule waives the Recovery Audit Contractor (RAC) requirements in subpart Z of Part 423 for the LI NET program.

- Technical corrections are proposed for § 423.505(b)(22) and the header of subpart Z of Part 423.

- The proposed rule clarifies the documentation required for enrollment in LI NET and the role of documentation in determining LIS eligibility.

- The eligibility for the full Low-Income Subsidy (LIS) for Medicare Part D prescription drug coverage has been expanded to individuals with incomes below 150% of the Federal Poverty Level (FPL) who meet certain resource standards, starting from January 1, 2024.

- The resource limits for the full subsidy will apply to years 2007 through 2023, and for years beginning on or after January 1, 2024, the resource standards currently applicable for the partial subsidy will apply to full subsidy eligible individuals.

- Individuals with incomes between 135 and 150 percent of the FPL and who meet the resource requirements will now qualify for the full subsidy beginning in 2024, and will be entitled to a premium subsidy of 100 percent of the premium subsidy amount.

- Commenters overwhelmingly supported the proposal to expand eligibility for the Part D LIS, stating that it will advance health equity, increase the affordability of prescription drugs, and facilitate access to care, especially for individuals with ESRD, and Black and Hispanic beneficiaries.

- CMS will conduct direct-to-consumer outreach to promote MSP and LIS enrollment in 2024, and will send notices in the Fall of 2023 to individuals who will be transitioning from the partial LIS subsidy to the full subsidy to inform them of the increased assistance they will be receiving beginning January 1, 2024.

- CMS has finalized several regulatory updates in the MA program related to health equity, including requirements intended to ensure equitable access to MA services, ensure MA provider directories reflect providers’ cultural and linguistic capabilities and notate MOUD-waivered providers, and ensure MA organizations incorporate one or more activities into their overall quality improvement program that reduce disparities in health and health care among their enrollees.

Context
The Centers for Medicare & Medicaid Services (CMS) is a federal agency responsible for administering the Medicare and Medicaid programs in the United States. Medicare is a health insurance program that provides coverage to individuals aged 65 and older, as well as those with certain disabilities or chronic conditions. CMS also oversees the Programs of All-Inclusive Care for the Elderly (PACE) programs, which provide comprehensive medical and social services to frail elderly individuals who prefer to live in their own homes or communities.

Recently, CMS issued new regulations aimed at improving health equity and access to care for Medicare beneficiaries with social risk factors (SRFs). The regulations include updates related to Star Ratings, marketing and communications, provider directories, coverage criteria, prior authorization, passive enrollment, network adequacy, and other programmatic areas. Additionally, eligibility for the Low-Income Subsidy (LIS) Medicare Part D program has been expanded to include individuals with incomes below 150% of the Federal Poverty Level who meet certain resource standards. These changes are expected to increase access to care and improve health outcomes for eligible beneficiaries. However, further research may be needed on their impact on healthcare providers and insurers as well as political implications.

Overall CMS will continue monitoring these programs while working towards ensuring equitable access across all demographics while reducing disparities in healthcare among enrollees.

Learn More
- https://www.cms.gov/newsroom/fact-sheets/2024-medicare-advantage-and-part-d-final-rule-cms-4201-f
2024 Medicare Advantage and Part D Final Rule (CMS-4201-F)
On April 5, 2023, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that revises the Medicare Advantage (MA or Part C), Medicare Prescription Drug Benefit (Part D), Medicare Cost Plan, and Programs of All-Inclusive Care for the Elderly (PACE) regulations to implement changes related to Star Ratings, marketing and communicati...

- https://www.cms.gov/about-cms/agenc...uity-programs/cms-framework-for-health-equity
CMS Framework for Health Equity | CMS - Centers for Medicare & Medicaid ...
Health Equity Programs CMS Framework for Health Equity CMS Framework for Health Equity En Español Newly Released: CMS Framework for Health Equity CMS released an updated framework to further advance health equity, expand coverage, and improve health outcomes for the more than 170 million individuals supported by CMS programs.

- [EXTERNAL LINK] - 2024 Final Rule: CMS Announces More Changes to Medicare Advantage but Declines to Reform the “60 Day Rule”
CMS Changes Medicare Advantage but Declines to Reform 60 Day Rule
The CMS released 24 Medicare Advantage and Prescription Drug Benefit Programs Final Rule which will be codified at 42 C.F.R. Parts 417 422 423 455 and 460. Adopts reforms to improve health care ...

Counterarguments
While the Centers for Medicare & Medicaid Services (CMS) has issued a final rule to revise regulations related to the Medicare Advantage (Part C), Medicare Prescription Drug Benefit (Part D), and other programs, it is important to note that there may be potential issues or concerns with the new provisions. While no obvious weaknesses or logical fallacies were identified in the information provided, it is possible that additional analysis could reveal limitations or alternative points of view.

One potential concern is that some of the changes may not go far enough in addressing health equity and ensuring access to care for all enrollees. While the inclusion of a health equity index reward and requirements for MA organizations to incorporate activities that reduce disparities in health care are positive steps, there may still be gaps in coverage and access for certain populations. Additionally, while the expansion of eligibility for the Low Income Subsidy (LIS) program is a positive development, it remains to be seen how effective this will be in increasing affordability and access to prescription drugs.

Overall, while the CMS final rule represents an effort to improve regulations related to Medicare Advantage and other programs, it will be important to continue monitoring its implementation and effectiveness in addressing key issues such as health equity and access to care.

Shortform Summaries