CMS: FAQ’s on CMS Waivers, Flexibilities, and the end of the COVID -19 Public Health Emergency

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The Department of Health and Human Services is planning for the federal Public Health Emergency for COVID-19 (PHE), declared under Section 319 of the Public Health Service Act, to expire at the end of the day on May 11, 2023. Today, the Centers for Medicare & Medicaid Services (CMS) issued FAQs on CMS Waivers, Flexibilities, and the End of the COVID-19 PHE. The FAQs will help you prepare for the expiration of the COVID-19 PHE and are relevant for all CMS programs; including, Medicare, Medicaid, the Children’s Health Insurance Program (CHIP), and private insurance.

CMS resources for the expiration of the COVID-19 PHE:

 

CMS UPDATE

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FOR IMMEDIATE RELEASE
April 17, 2023

Contact: CMS Media Relations
CMS Media Inquiries

Today, the Biden-Harris Administration, through the Centers for Medicare & Medicaid Services (CMS), announced measures that will make coverage more accessible, expand behavioral health care access, simplify choice, and make it easier for millions of Americans to select a health plan in 2024. 

“The Biden-Harris Administration has worked tirelessly to expand access to health insurance and lower health care costs for America’s families,” said HHS Secretary Xavier Becerra. “Today’s announcement of the 2024 Notice of Benefit and Payment Parameters Final Rule is a step forward toward creating a health care system which prioritizes equity, access, and affordability. HHS remains committed to removing barriers to care to ensure quality health care is within reach for everyone who needs it.” 

“We’ve made great progress with record insured rates, but affordable health care remains a concern across the nation,” said CMS Administrator Chiquita Brooks-LaSure. “As we continue to work toward accessible and equitable health care for all Americans, the 2024 Notice of Benefit and Payment Parameters Final Rule we’re finalizing today will make it easier for consumers to access, choose and maintain the health coverage that best fits their needs.”

The 2024 Notice of Benefit and Payment Parameters Final Rule (final 2024 Payment Notice) finalizes standards for issuers and Marketplaces, as well as requirements for agents, brokers, web-brokers, and Assisters that help consumers with enrollment through Marketplaces that use the federal platform. These changes further the Biden-Harris Administration’s goals of advancing health equity by addressing the health disparities that underlie our health system, such as strengthening network adequacy standards and creating a new special enrollment period (SEP) for those who lose Medicaid or Children’s Health Insurance Plan (CHIP) coverage, among others. The rule also builds on the Affordable Care Act by expanding access to quality, affordable health coverage and care, especially behavioral health care, and making it easier to select and enroll in health coverage. 

Making it easier to enroll in coverage 

While the administration previously announced a temporary SEP for individuals losing Medicaid or CHIP until July 31, 2024 in recognition of the end of the continuous coverage requirement in Medicaid, the final rule establishes a permanent policy. Beginning January 1, 2024, Federally-facilitated Marketplaces (FFMs) and State-based Marketplaces (SBMs) will have the option to implement a new SEP for people losing Medicaid or CHIP coverage, allowing consumers to select a plan for Marketplace coverage 60 days before, or 90 days after, losing Medicaid or CHIP coverage. This SEP works to reduce gaps in coverage and allows for a more seamless transition into Marketplace coverage. 

The final rule also allows Assisters to provide more convenient and efficient help to consumers.  Assisters currently conduct direct outreach, education, and schedule follow-up appointments, but are generally prohibited from providing enrollment assistance upon an initial interaction if initiated by the Assister. Removing this barrier will make it easier for consumers to get help when enrolling in coverage. Additionally, this policy change will likely improve health literacy in rural and underserved communities and reduce burden on consumers, especially for consumers with a lack of access transportation, inflexible job schedules, and those who are immunocompromised. 

Increasing access to health care services 

Expanding access to behavioral health care remains a top priority for the Biden-Harris Administration. As part of that effort, the final rule includes two new essential community provider (ECP) categories that are critical to delivering needed behavioral health care: Substance Use Disorder Treatment Centers and Mental Health Facilities. 

The final rule will also help expand access to care by extending the requirement for plans to contract with at least 35% of available ECPs in a plan’s service area to apply to two individual ECP categories: Federally Qualified Health Centers and Family Planning Providers. The overall 35% threshold requirement also remains in place. These changes, in conjunction with other expanded Network Adequacy requirements in the final rule, increase provider choice, advance health equity, and expand access to care for consumers who have low incomes, complex or chronic health care conditions, or who reside in underserved areas, as these consumers are often disproportionately affected by unanticipated costs associated with out-of-network providers and limited access to providers. 

Simplifying choice and improving the plan selection process 

The final rule includes provisions to make it easier for consumers to select a health plan that best fits their individual needs and budget by refining designs for standardized plan options. The final rule is also limiting the number of non-standardized plan options offered by issuers of qualified health plans (QHPs) through the FFMs and SBMs on the Federal Platform (SBM-FPs) to four in each area for the 2024 plan year. This will reduce plan choice overload while continuing to provide a robust number of options for consumers to help fit their health needs. 

For more information on the final rule, consult the fact sheet: https://www.cms.gov/newsroom/fact-sheets/hhs-notice-benefit-and-payment-parameters-2024-final-rule

How 2024 Medicare Part D drug coverage is changing and will help save on prescription costs.

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Article from Q1Medicare.com

Category: Annual Medicare Plan Changes
Published: Apr, 04 2023 09:04:59

The Centers for Medicare and Medicaid Services (CMS) released the “Announcement of Calendar Year (CY) 2024 Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies” (Rate Announcement) on March 31, 2023 and the 2024 Rate Announcement includes the finalized defined standard Part D benefit increases for 2024 Medicare drug plan coverage.

 

READ FULL ARTICLE HERE! 

HHS Updates 2024 Medicare Advantage Program and Part D Payment Policies

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CMS NEWS

 

FOR IMMEDIATE RELEASE

March 31, 2023

 

Contact: CMS Media Relations

(202) 690-6145 | CMS Media Inquiries

HHS Updates 2024 Medicare Advantage Program and Part D Payment Policies

 

Updated Medicare Advantage and Part D policies ensure the overall Medicare program remains strong and stable for the 65 million beneficiaries today and future generations to come, payments to private insurance companies are accurate, and taxpayer dollars are well spent.

Today, the U.S. Department of Health and Human Services (HHS), through the Centers for Medicare & Medicaid Services (CMS), released the Calendar Year (CY) 2024 Medicare Advantage (MA) and Part D Rate Announcement that finalized payment policies for these programs. The final policies in the Rate Announcement improve payment accuracy and ensure taxpayer dollars are well spent. CMS will phase-in certain updates, and on average, CMS anticipates a payment increase for MA plans of 3.32% from 2023 to 2024, which is approximately a $13.8 billion increase in MA payments for next year.

The Biden-Harris Administration is committed to protecting and strengthening Medicare, and delivering quality health care for Medicare beneficiaries today and in the future. Today’s payment rule will ensure that benefits remain strong and stable for beneficiaries and that payments are accurate and appropriate. The Administration is committed to holding health insurance companies that participate in the Medicare Advantage program accountable to America’s seniors.

“This year’s update strengthens Medicare for our seniors and Americans with disabilities,” said HHS Secretary Xavier Becerra. “We are committed to ensuring private companies are holding up their end of the deal to provide quality care to beneficiaries and that payments to these companies are accurate. Together with President Biden’s Budget, this update protects Medicare for beneficiaries today and beyond 2050.”

“Medicare should be providing equitable, high-quality affordable care that will be available for our children and grandchildren,” said CMS Administrator Chiquita Brooks-LaSure. “Paying Medicare Advantage plans more accurately for the care they provide is how we ensure that people enrolled in Medicare Advantage, especially populations with the highest health disparities and people in underserved communities, can continue to access the care they deserve.”

In addition to today’s final rule, the Biden-Harris Administration has taken action to make the Medicare program stronger and hold industry accountable. This year, it will start recovering improper payments made to insurance companies in Medicare Advantage. Recovering these improper payments and returning this money to the Medicare Trust Funds will protect the fiscal sustainability of Medicare and allow the program to better serve seniors and people with disabilities.

The Administration has also proposed policies to strengthen the MA managed care program that will hold health insurance companies to higher standards by:

  • cracking down on abusive and confusing marketing schemes;
  • addressing problematic prior authorization practices that prevent timely access to needed care;
  • making it easier to access vital behavioral health care; and
  • raising the bar on quality and driving toward more equitable care.

Taken together, these actions will make the overall Medicare program stronger.

“The commonsense policies in the Rate Announcement ensure these important programs continue to meet the health care needs of all people with Medicare while improving the quality and long-term stability of the Medicare program,” said CMS Deputy Administrator and Director of the Center for Medicare Meena Seshamani, MD, Ph.D.

The Rate Announcement finalizes updates to MA payment growth rates and changes to the MA and Part D payment methodologies. These include technical and clinical updates to the MA risk adjustment model to keep it up to date and improve payment accuracy. Two such changes are the transition to the Internal Classification of Diseases (ICD)-10 system, which is the coding classification system used throughout the U.S health care system since 2015, and updated data years. Modernizing the Medicare Advantage risk adjustment model by aligning it with the ICD-10 system will ensure the payment models are using more up-to-date data – bringing Medicare Advantage payments in line with current health care practices and making them consistent with other federal health care programs. The finalized risk adjustment model also reflects revisions focused on conditions that are subject to more coding variation. As in past years, CMS is finalizing policies to address these inconsistencies in order to ensure the model more accurately predicts medical costs.

The changes in risk adjustment payment policies finalized as part of this Rate Announcement were developed in collaboration with expert clinicians to take into account how well different conditions predict costs. The policies finalized in this Rate Announcement will help make more accurate payments. This reduces incentives to cherry-pick healthy beneficiaries and discriminate against sicker patients. In addition, CMS will continue to pay more for someone who is dually eligible for Medicare and Medicaid than someone who is not when they have the same diagnoses.

In finalizing these proposed policies, CMS is making commonsense updates to ensure the MA program remains strong and viable. Consistent with prior practice, CMS will phase in both the technical revisions to the risk adjustment model and changes to the per capita cost calculations to better account for medical education costs over a period of three years.

View a fact sheet on the CY 2024 Medicare Advantage and Part D Rate Announcement.

The 2024 Rate Announcement can be viewed at https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Announcements-and-Documents and selecting “2024 Announcement.”

 

CMS Press Release: HHS Secretary Responds to the President’s Executive Order on Drug Prices

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FOR IMMEDIATE RELEASE
February 14, 2023 

Action announces new models and supports access to $2 generic drugs

Today, the Centers for Medicare & Medicaid Services (CMS) announced that the Secretary of the Department of Health and Human Services (HHS) has selected three new models for testing by the CMS Innovation Center to help lower the high cost of drugs, promote accessibility to life-changing drug therapies, and improve quality of care. The Secretary released a report describing these three models to respond to President Biden’s Executive Order 14087, “Lowering Prescription Drug Costs for Americans,” which complements the historic provisions in the Inflation Reduction Act of 2022 (IRA) that will lower prescription drug costs.

“HHS is using every tool available to us to lower health care costs and increase access to high-quality, affordable health care,” said HHS Secretary Xavier Becerra. “We are full steam ahead in delivering the cost savings from the President’s Inflation Reduction Act of 2022, and people on Medicare are already feeling the benefits. But as President Biden has made clear, we must build on the new prescription drug law with further action, which is why HHS is implementing these new projects to bring down prescription drug costs.”

“Prescription drug prices in the United States are the highest in the developed world, resulting in affordability and access challenges,” said CMS Administrator Chiquita Brooks-LaSure. “The prescription drug law is making lifesaving prescription drugs more affordable for millions of people who have Medicare, and through the selected models, the Innovation Center will lower prescription drug costs and improve access for people with Medicare and Medicaid, ranging from $2 access to certain generic drugs to better deals for expensive new therapies.”

Tackling the high costs of prescription drugs and increasing access to novel therapies continue to be priorities of the Biden-Harris Administration. As part of the Inflation Reduction Act of 2022, for the first time in history, Medicare will be able to negotiate lower prescription drug prices for beneficiaries, and starting this year, drug companies that raise their prices faster than inflation will have to pay Medicare a rebate. But the Administration recognizes there is more work to do to lower prescription drug costs for more American families. That’s why on October 14, 2022, President Biden issued an executive order directing Secretary Becerra to consider additional actions to further drive down prescription drug costs. In particular, the executive order directs the Secretary to consider whether to select for testing, by the CMS Innovation Center, new health care payment and delivery models that would lower drug costs and promote access to innovative drug therapies for beneficiaries enrolled in the Medicare and Medicaid programs, including models that may lead to lower cost-sharing for commonly used drugs and support value-based payment that promotes high-quality care.

“These selected models will test strategies to make it easier for Medicare patients to afford and access needed prescriptions at $2 or less, help expand access to cutting-edge cell and gene therapies for people with Medicaid, and help ensure drugs already on the market are safe and effective,” said CMS Deputy Administrator and Director of the CMS Innovation Center Liz Fowler, PhD, JD. “We look forward to working on these models and helping to lower drug costs for Americans with Medicare and Medicaid.”

The three models selected by the Secretary for testing by the CMS Innovation Center and described in the report address the themes outlined in the executive order and meet the selection criteria thresholds of affordability, accessibility, and feasibility of implementation. The models are:

  • The Medicare $2 Drug List: For chronic conditions like high blood pressure and high cholesterol, there are many relatively inexpensive generic medications that have significant clinical benefits, but cost-sharing can vary widely across insurance plans based on the specific formulation a doctor prescribes. This means patients may experience unexpected changes in their cost-sharing and may pay more than they have to. Under this model (the Medicare High-Value Drug List Model), Part D plans would be encouraged to offer a low, fixed co-payment across all cost-sharing phases of the Part D drug benefit for a standardized Medicare list of generic drugs that treat chronic conditions. Patients picking plans that participate in the Model will have more certainty that their out-of-pocket costs for these generic drugs will be capped at a maximum of $2 per month per drug.
  • The Cell and Gene Therapy Access Model: Cell and Gene Therapies are an emerging area of new drug development that holds significant potential, but these therapies can cost upwards of $1 million. Under this model, state Medicaid agencies would assign CMS to coordinate and administer multi-state, outcomes-based agreements with manufacturers for certain cell and gene therapies. As new therapies come to market, this will help Medicaid beneficiaries gain access to potentially life-changing, high-cost specialty drugs for illnesses like sickle cell disease and cancer.
  • The Accelerating Clinical Evidence Model: Some drugs are approved before they have established evidence of improvement in a clinical endpoint, which is called accelerated approval. CMS would develop payment methods for drugs approved under accelerated approval, in consultation with the Food and Drug Administration, to encourage timely confirmatory trial completion and improve access to post-market safety and efficacy data. This would reduce Medicare spending on drugs that have no confirmed clinical benefit.

To help identify model options, the CMS Innovation Center solicited input from a variety of sources, including beneficiary advocates, health care providers, prescription drug manufacturers, and more. The CMS Innovation Center looks forward to additional input as these models are further developed.

In addition to the three selected models, the Secretary has identified additional areas for research with the potential to lower prescription drug costs. The CMS Innovation Center looks forward to feedback on these ideas and will continue research into the design and feasibility of these ideas.

For more information on the selected models and the additional areas of research that address the executive order, a Fact Sheet is available at https://innovation.cms.gov/data-and-reports/2023/eo-rx-drug-cost-response-report-summary.

Frequently Asked Questions are available at https://innovation.cms.gov/data-and-reports/2023/eo-rx-drug-cost-response-report-faqs.

View the report at https://innovation.cms.gov/data-and-reports/2023/eo-rx-drug-cost-response-report.

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Biden Administration Releases Timeline IRA Medicare Provisions

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Biden Administration Releases Timeline for Implementation of Inflation Reduction Act Medicare Provisions

The administration released a timeline for implementation of certain Inflation Reduction Act (IRA) provisions, including provisions related to Medicare drug price negotiations.

As we have mentioned previously, the IRA grants the secretary of HHS the ability to negotiate the prices of certain drugs for the Medicare program with new prices beginning in 2026. Ten Part D drugs will be negotiated in 2026, with an additional 15 Part D drugs in 2027, 15 Part B or D drugs in 2028, 20 Part B or D drugs in 2029, and 20 more drugs each year beyond that. The bill dictates that the secretary can only negotiate prices on costly single-source drugs, those among the highest-spend products in Part B or Part D that do not have competing small-molecule generics or biosimilars that are both FDA-approved and marketed. The legislation also exempts “small biotech drugs” from negotiation until 2028….

 

READ FULL ARTICLE

PLUS! DOWNLOAD A CMS PDF OF THE IRA TIMELINE FOR A QUICK REFERENCE 

CMS Med Advantage Reminder: Addition of Race and Ethnicity Data Fields on Enrollment Transactions for 2023

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SUBJECT: Model Individual Enrollment Request Form to Enroll in a Medicare Advantage Plan (MA) or a Medicare Prescription Drug Plan (Part D), and Advance Announcement of January 2023 Software Release – Addition of Race and Ethnicity Data Fields on Enrollment Transactions

 

The Centers for Medicare & Medicaid Services (CMS) implements software changes to the enrollment and payment systems that support Medicare Advantage Prescription Drug (MAPD) programs. The purpose of this memorandum is to announce the addition of race and ethnicity data fields on the model Individual Enrollment Request Form to enroll in an MA or Part D plan, OMB No. 0938-1378 and provide high level advance notification of the associated system changes scheduled for release in January 2023. These new fields are required to be included on the enrollment form; however, applicant response to these questions is optional. When provided by an applicant, MA and Part D plans will submit these data to CMS as part of the enrollment transaction. If a plan receives a rejected transaction reply code (TRC) 394 or informational TRC 396 (see attachment C), the plan must send a subsequent corrected transaction code (TC) 92 to rectify. CMS expects plans to submit the beneficiary response to the race and ethnicity field, including confirming if the beneficiary did not provide the optional data. Until all race and ethnicity data are accepted by CMS, including annotating that the beneficiary did not answer the question, the field is not considered complete.

 

READ FULL PRESS RELEASE 

VIEW FULL TIMELINE

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CMS Implementation Timeline

2022

Affordable Care Act

  • People covered under the Affordable Care Act insurance plans will continue to save on their health insurance coverage during Open Enrollment for 2023 coverage.

Medicare Part B qualifying biosimilars

  • Starting Oct. 1, Medicare will temporarily pay an add-on fee of 8% instead of 6% for qualifying biosimilars.  This increase will encourage competition, lower costs for prescription drugs, and improve patient access to biosimilars.

Medicare Part D drug rebates

  • Oct. 1 is the start of the first 12-month period for which drug manufacturers will be required to pay rebates to Medicare if their prices for certain Part D drugs increase faster than the rate of inflation over the 12-month period.  The Part D inflation rebates for the 12-month periods beginning Oct. 1, 2022 and Oct. 1, 2023 must be invoiced by December 31, 2025.

VIEW FULL TIMELINE

CMS Press Release 10.18.22

CMS Final Rule Part B and others

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FOR IMMEDIATE RELEASE
October 28, 2022

Contact: CMS Media Relations
CMS Media Inquiries

Biden-Harris Administration Strengthens Medicare with Finalized Policies to Simplify Enrollment and Expand Access to Coverage

Final rule creates Special Enrollment Periods and reduces gaps in Medicare coverage, and improves administration of the Medicare Savings Programs.

Today, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that updates Medicare enrollment and eligibility rules to expand coverage for people with Medicare and advance health equity. The final rule, which implements changes made by the Consolidated Appropriations Act, 2021 (CAA), makes it easier for people to enroll in Medicare and eliminates delays in coverage. Among these changes, individuals will now have Medicare coverage the month immediately after their enrollment, thereby reducing any delays in coverage.  In addition, the rule expands access through Medicare special enrollment periods (SEPs) and allows certain eligible beneficiaries to receive Medicare Part B coverage without a late enrollment penalty.

The Biden-Harris Administration has made expanding access to health care a top priority, and, under their leadership, more Americans than ever before have health insurance coverage. Today’s final rule builds on this success and supports additional Administration efforts to strengthen Medicare.

“The Biden-Harris Administration has made it clear: we are committed to doing all we can to strengthen Medicare,” said HHS Secretary Xavier Becerra. “Today, we’re making it easier to enroll, expanding access, and eliminating delays in coverage to improve Medicare for the millions of Americans who depend on it. We’re working tirelessly to deliver the health insurance and peace of mind that enrollees deserve.”

“CMS is committed to ensuring that people eligible for Medicare have timely access to this vital coverage,” said CMS Administrator Chiquita Brooks-LaSure. “For the first time, special enrollment periods will be available in traditional Medicare for individuals who were unable to enroll due to exceptional conditions, and individuals who have had a kidney transplant will now be able to receive extended Medicare coverage for immunosuppressive drugs.  Each part of this critical rule advances CMS’ strategic vision of expanding access to quality, affordable health coverage and care.”

A Special Enrollment Period (SEP) lets individuals make changes to their health coverage outside of a typical enrollment period. The SEPs finalized in this rule provide an opportunity for eligible individuals to enroll in Part B if they didn’t enroll in Medicare during their Initial Enrollment Period when they were first eligible, and to do so without a late enrollment penalty. Examples of new SEPs created by this rule are SEPs for eligible individuals who miss an enrollment opportunity because: 1) they were impacted by a disaster or government-declared emergency; 2) their employer or health plan materially misrepresented information related to timely enrollment in Medicare Part B; 3) they were incarcerated; and 4) their Medicaid coverage was terminated after the COVID-19 PHE ends or on or after January 1, 2023 (whichever is earlier).

The final rule also establishes a new immunosuppressive drug benefit that extends vital Medicare immunosuppressive drug coverage to certain individuals who have had a kidney transplant and otherwise would lose Medicare coverage. The changes finalized in this rule go into effect on January 1, 2023.

These changes not only implement important provisions of the Consolidated Appropriations Act, 2021 (CAA), but also support President Biden’s Executive Orders on Transforming Federal Customer Experience and Service Delivery to Rebuild Trust in Government and Continuing to Strengthen Americans’ Access to Affordable, Quality Health Coverage by eliminating confusing coverage waiting periods and allowing CMS and the Social Security Administration to remedy missed enrollment periods by permitting eligible individuals to enroll in Medicare Part B through SEPs for exceptional conditions. Furthermore, these changes support the Administration’s vision for CMS: to serve the public as a trusted partner and steward, dedicated to advancing health equity, expanding access to affordable coverage and care, and improving health outcomes.

“These changes highlight CMS’ efforts to advance health equity and improve access to Medicare,” said Dr. Meena Seshamani, Deputy Administrator of CMS and Director of the Center for Medicare. “Reducing gaps in coverage, allowing for special enrollment periods for individuals in exceptional circumstances, spending money in a smarter way on kidney transplant patients – these are meaningful changes that put people at the center of their care and improve the Medicare program.”

Finally, CMS is making several technical updates to improve administration of the Medicare Savings Programs. These programs help make Medicare affordable for those struggling to afford health care.

CMS encourages people who are approaching Medicare eligibility to research their Medicare coverage options and enrollment deadlines. Medicare.gov and 1-800-MEDICARE are both available to help people understand their choices and associated deadlines. In addition, personalized health insurance counseling is available at no cost from State Health Insurance Assistance Programs (SHIPs). Visit shiptacenter.org or call 1-800-MEDICARE for each SHIP’s phone number.

Medicare Open Enrollment runs from October 15 to December 7, 2022. During this time, people eligible for Medicare can compare 2023 coverage options on Medicare.gov. Medicare.gov provides clear, easy-to-use information, as well as an updated Medicare Plan Finder, to allow people to compare options for health and drug coverage, which may change from year to year.

Medicare Plan Finder was updated with the 2023 Medicare health and prescription drug plan information on October 1, 2022. 1-800-MEDICARE is also available 24 hours a day, seven days a week to provide help in English and Spanish as well as language support in over 200 languages. People who want to keep their current Medicare coverage do not need to re-enroll.

During Open Enrollment, people with Medicare who take insulin are encouraged to call 1-800-MEDICARE or contact their State Health Insurance Assistance Programs (https://www.shiphelp.org/) for help comparing plans and costs this year.

To view a fact sheet on the final rule, visit: https://www.cms.gov/newsroom/fact-sheets/implementing-certain-provisions-consolidated-appropriations-act-2021-and-other-revisions-medicare-2

To view the final rule, visit: https://www.federalregister.gov/public-inspection/2022-23407/medicare-program-implementing-certain-provisions-of-the-consolidated-appropriations-act-2021-and

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CMS Marketing Best Practices + Agent Broker Marketing FAQ

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DEPARTMENT OF HEALTH & HUMAN SERVICES | Centers for Medicare & Medicaid Services | Center for Medicare
DATE: October 19, 2022
TO: All Medicare Advantage Organizations and Prescription Drug Plan Sponsors
FROM: Kathryn A. Coleman Director
SUBJECT: CMS Monitoring Activities and Best Practices during the Annual Election Period

The Centers for Medicare & Medicaid Services (CMS) issues this memorandum informing Medicare Advantage (MA) organizations and Part D sponsors of CMS monitoring activities and sharing plan and sponsor best practices during the 2023 Annual Election Period (AEP), running from October 15, 2022 to December 7, 2023.

CMS is concerned about the marketing practices of all entities, including Third-Party Marketing Organizations. We have reviewed thousands of complaints and hundreds of audio calls and have identified numerous issues with information provided to beneficiaries that is confusing, misleading and/or inaccurate. CMS has conducted so-called “secret shopping” by calling numbers associated with television advertisements, mailings, newspaper advertisements, and internet searches to monitor the experience beneficiaries have engaging these entities. Our secret shopping activities have discovered that some agents were not complying with current regulation and unduly pressuring beneficiaries, as well as failing to provide accurate or enough information to assist a beneficiary in making an informed enrollment decision.  READ THE FULL RELEASE: HPMS Marketing Practices Memo

Contract Year 2023 Medicare Advantage Marketing Policies – Frequently Asked Questions
On May 9, 2022, CMS published its contract year 2023 Medicare Advantage (MA) (Part C) and Prescription Drug Benefit (Part D) final rule (87 FR 27704), wherein CMS established certain marketing and communications requirements for the Part C and Part D programs. These rules were designed to address complaints of inappropriate marketing that CMS received from beneficiaries and their caregivers. In response to a significant increase in marketing-related complaints, CMS staff reviewed numerous recordings of calls from different marketing entities, including individual agents and brokers, as well as larger call centers. The agents failed to provide the beneficiary with the necessary information or provided inaccurate information to make an informed choice for more than 80 percent of the calls reviewed. Examples included beneficiaries being told that if their medication was not on the formulary, the doctor could tell the plan and the plan would simply add it; or incorrectly stating that “nothing would change” when beneficiaries asked if their current health coverage would stay the same.
As 2023 annual open enrollment begins, CMS has received questions regarding these changes, including , the requirement related to recording calls between beneficiaries and Third-Party Marketing Organizations (TPMOs) and the requirements related to the TPMO disclaimer.  READ THE FULL RELEASE: Agent Broker Marketing FAQs_10.19.2022