On April 5, 2019, the Centers for Medicare and Medicaid Services released a final rule of administrative and technical changes to Medicare Advantage and Medicare Part D. Many of the changes in this rule were mandated by the Bipartisan Budget Act of 2018 (BBA). Most of the provisions in this final rule will go into effect on January 1, 2020.

Beneficiaries Gain Access to Expanded Telehealth Benefits in 2020

• The BBA allows MA plans to offer expanded access to telehealth benefits, starting in the 2020 plan year, treating them as a basic benefit. This final rule establishes a corresponding regulatory requirement for MA plans.
• Telehealth benefits will be offered as part of the “basic benefit package” meaning MA plans may build costs into their bids, and the costs will be subsidized through the Medicare program. Telehealth benefits are no longer supplemental benefits.
• Telehealth benefits will be limited to services that are offered under Medicare part B and must be identified as clinically appropriate to deliver via electronic exchange. CMS chose not to define “clinically appropriate” to better allow for flexibility.
• MA plans must be able to provide information on telehealth benefits to CMS upon request to enable the agency to evaluate the impacts of telehealth as a basic benefit.
• MA plans cannot restrict coverage of a specific service to telehealth; if a service is covered via telehealth, the same service must also be covered in-person.

Prescription Drug Plans Will be Able to Request Access to Parts A and B Claims Data

• The BBA directs the agency to establish a process for prescription drug plan (PDP) sponsors to request claims data of plan enrollees, which would include a subset of claims from Parts A and B
• The data may be used for the following purposes:
  • Enhancing therapeutic outcomes through improved use of medication
  • Improving care coordination to prevent adverse outcomes
• The claims data cannot be used to inform coverage determinations, conduct retroactive reviews of medically accepted conditions, facilitate enrollment changes to a different plan offered by the same parent organizations, or inform marketing of benefits.
• CMS will be allowed to refuse release of the data if the agency determines the sponsor has used the data for unauthorized purposes

CMS Finalizes Updates to MA and Part D Preclusion List

• In April 2018, CMS formally eliminated requirements that MA and Part D plans only cover prescriptions written by prescribers meeting Medicare enrollment requirements, regardless of whether the provider accepted Medicare reimbursement.
• Instead, CMS established a “preclusion list” which contains the names of prescribers meeting certain risk factors and for which payment for prescriptions written by these providers would be denied.
• If a provider or entity has their ability to bill Medicare revoked, they must be placed on the preclusion list within 5 months. Providers will not be placed on the preclusion list until they have exhausted their first level of appeal.
• A provider excluded from Medicare based on an order from the Office of the Inspector General (OIG) will be immediately added to the preclusion list, regardless of appeal status.
• MA and Part D plans will be required to notify beneficiaries that his or her prescriber has been added to the preclusion list within 30 days of the addition. Plans must then wait 60 days before denying claims for prescriptions written by that prescriber.

D-SNPs Will be Required to Integrate Medicare, Medicaid Benefits and Institute Unified Grievance and Appeals Process

• This rule finalizes new requirements consistent with the Bipartisan Budget Act of 2018 related to the minimum criteria for Medicare and Medicaid integration for 2021 and beyond in Dual eligible Special Needs Plans (D-SNPs).
• The standards for integration require all D-SNPs to cover Medicaid benefits through a capitated payment from a state Medicaid agency or by meeting a minimum set of requirements established by CMS.
• A D-SNP found to be out of compliance with integration requirements during plan years 2021 through 2025 will face an enrollment suspension.
• D-SNPs must have a unified grievance and appeals process finalized April 2020 for use in plan year 2021 and beyond.

CMS Finalizes Technical Updates to Star Ratings Measures

• CMS is finalizing updates to the cut points for the Consumer Assessment of Healthcare Providers and Systems (CAHPS) measures and finalizing updates to specifications for measures in the 2022 and 2023 Star Ratings.
• Changes will impact the 2020 data collection year and all substantive measures changes in the Star Ratings will be proposed through rulemaking.

MA Risk Adjustment Data Validation Procedure Changes Not Discussed in Final Rule Due to Extended Comment Period

• The proposed rule had included updated provisions updating the Risk Adjustment Data Validation (RADV).

However, the Agency issued an extended comment period on this topic; comments are due April 30, 2019. As such, RADV is not discussed in this final rule, but instead will be addressed in subsequent rulemaking.