Medicare Regulatory Compliance Updates
There are several upcoming changes to the Medicare regulatory landscape, and to help keep you informed, we’ve summarized a few of the more significant ones here:
Inflation Reduction Act’s Medicare Prescription Payment Plan
CMS recently issued additional draft guidance on the Inflation Reduction Act’s Medicare Prescription Payment Plan, outlining requirements for Medicare Part D plan sponsors, pharmacy processes, and operational considerations, which would take effect in January 2025.
The Medicare Prescription Payment Plan will help reduce the burden of high upfront out-of-pocket prescription drug costs for individuals with Medicare prescription drug coverage by allowing them to spread out costs over the year rather than requiring they pay in one lump sum.
In addition to adding flexibility through a payment plan, the law cuts drug costs through provisions such as caps on out-of-pocket costs and the cost of insulin, and a mandate on drug companies to pay a rebate to Medicare if they raise prices faster than inflation.
Read more about the Medicare Prescription Payment Plan here.
CMS Medicare Part D Guidance
The Centers for Medicare & Medicaid Services (CMS) released final part one guidance for the new Medicare Prescription Payment Plan, which begins in 2025. This guidance focuses on:
identifying Medicare Part D enrollees likely to benefit from the program;
opt-in process for Part D enrollees;
program participant protections; and
data collection to evaluate the program.
The final part one guidance includes a requirement that Part D sponsors must notify pharmacies to provide information on the Medicare Prescription Payment Plan to Part D beneficiaries who meet a $600 out-of-pocket threshold based on a single prescription at the point-of-sale.
Draft part two guidance for the program was published on February 15.
Indiana Medicare Supplement Under Age 65 Update
Indiana’s Governor signed Senate Bill 215, which amends the current Medicare Supplement regulation making plans available to individuals under age 65.
Currently the state requires that carriers make Plan A available to individuals eligible for Medicare due to disability, if applied for within six months of Part B enrollment.
After December 31, 2024, all plans offered by a Medicare Supplement carrier must also be made available to an individual eligible for Medicare by reasons of both disability and end-stage renal disease.
Medicare Supplement carriers may not charge a higher premium rate for individuals under age 65 compared to an individual who is 65 years of age for Plans A, B, and D. For all other plans, carriers cannot exceed 200% of the premium rate for an individual who is 65 years of age. In addition, carriers cannot impose waiting periods or pre-existing condition limitations for the under 65 eligibles.
DOI Responses to Change Healthcare Cyberattack
As evidenced by the recent cyberattack against Change Healthcare, information security plays a vital role in health insurance, and state insurance departments are taking notice.
For example, Maryland requires all insurers, nonprofit health service plans, health maintenance organizations, dental organizations, managing general agents, and third-party administrators doing business in Maryland to file a Certification of Compliance, certifying the carrier has a comprehensive written information security program based on the carrier’s risk assessment and a written incident response plan designed to promptly respond to, and recover from, a cybersecurity event.
The Certification of Compliance should be submitted by electronic form before April 15th annually.
Carriers who are domiciled in another state with substantially similar requirements are exempt from filing this certification in Maryland.
Utah has also provided guidance in Bulletin 2024-4, requesting insurers to:
Provide prompt assistance to consumers and healthcare providers in the coming weeks.
Update websites with instructions and materials on:
how consumers can get help accessing benefits
how healthcare providers can verify eligibility and get assistance submitting pre-authorizations, claims, and supporting documents.
Provide flexibility for appeal processes, prior authorizations, and other situations where the insurer and healthcare provider cannot electronically share information.
Extend proof of loss filing deadlines to all healthcare providers affected by the cyberattack for healthcare claims with dates of service February 1, 2024 through when providers' systems are fully restored.
For more regulatory compliance updates and reminders like these, check out the Compliance Chatter section in our weekly Medicare Market Insights newsletter.
With the increasing scrutiny of Medicare-related insurance product marketing, it is vital that any consumer-facing marketing content comply with The Centers for Medicare & Medicaid Services (CMS) Medicare marketing guidelines.
Did you know?
Materials or activities that mention any Medicare Advantage benefit, even widely available benefits such as dental, vision, and/or hearing, will be considered marketing and must be filed with HPMS.
Marketing materials may not advertise benefits that are unavailable in a service area unless it is unavoidable in the local media.
Marketing for the next plan year may not occur prior to October 1.
Marketing materials may not advertise benefits that are unavailable in a service area, unless it is unavoidable in the local media.
Telos Actuarial’s team of experienced regulatory compliance professionals can help you ensure your Medicare marketing content meets CMS marketing requirements.
Reach out to compliance@telosactuarial.com to learn more about the Compliance services we provide!
