Healthcare Business News

Rule would let CMS terminate poor-performing Advantage, Part D sponsors

By Jessica Zigmond
Posted: October 3, 2011 - 12:01 am ET

CMS on Monday proposed changes to the Medicare Advantage and prescription drug programs that would implement provisions outlined in last year's Patient Protection and Affordable Care Act.

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Open to a 60-day comment period, the proposed rule would provide the CMS with the authority to terminate poor-performing Medicare Advantage and Part D sponsors that fail to achieve at least a 3-star rating under the agency's 5-star plan rating system for a period of three years.

It would also allow fully integrated, dual eligible, special-needs plans, or SNPs, to offer supplemental benefits beyond those that exist currently for Medicare Advantage plans for patients who are eligible for both Medicare and Medicaid. These benefits include non skilled-nursing activities in the home and in-home food delivery for vulnerable patients, according to CMS.

Meanwhile, the proposed rule would require Medicare part D sponsors in certain cases to provide the option of a daily, pro-rated, cost-sharing rate for prescriptions for fewer than 30 days. And if a prescription is denied by a part D plan, the proposed rule would allow physicians to request reconsiderations with the independent review entity, or IRE, on their patient's behalf without obtaining a signed authorized representative form.

The regulation would also require pharmacy benefit managers under part D to report additional financial information in order to improve transparency.

“These changes would improve data collection and tracking, help better identify the prescriber of part D medications, and assist our law enforcement partners in the conduct of investigations when there is suspected fraud association with a prescription drug claim,” said a summary of the rule from CMS.

If it's made final, the rule would be effective in 2013.

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