Medicare Advantage, Part D Proposal Aims to Lower Beneficiary Cost Sharing and Assess Health Risks

January 10, 2022

On January 6, the Centers for Medicare & Medicaid Services (CMS) released the 2023 Medicare Advantage and Part D proposed rule. The proposal aims to advance the administration’s efforts to improve consumer protections, reduce disparities, and improve health equity in Medicare Advantage (MA) and Part D. Provisions of interest to the Association for Clinical Oncology (ASCO) include:

Beneficiary Part D Cost Sharing

This proposed rule would revise the MA and Part D regulations related to the use of pharmacy price concessions—where part D plans pay less money for dispensed drugs to pharmacies that do not meet certain criteria—to reduce beneficiary out of pocket costs for prescription drugs under Part D.

Currently, the negotiated price for a drug between Part D plans and pharmacies is the price reported to CMS at the point of sale and is used to calculate beneficiary cost-sharing. However, the negotiated price is frequently higher than the final payment pharmacies receive, and higher negotiated drug prices lead to greater beneficiary cost-sharing and faster beneficiary use of the Part D benefit.

CMS’ proposed rule would require Part D plans to apply all of the price concessions they receive from network pharmacies to the point of sale, so that the beneficiary can also share in the savings, essentially lowering the patient cost-sharing amount. Beginning January 1, 2023, the negotiated price for Part B drugs would be redefined as the baseline, or lowest possible, payment to a pharmacy, which the agency says will reduce beneficiary out-of-pocket costs.

Social Determinants of Health and Health Risk Assessments for Dual-Eligibles in Special Needs Plans

All Special Needs Plans (SNPs) must complete enrollee health risk assessments (HRAs) at enrollment and annually. CMS is proposing that all HRAs include specific standardized questions on housing stability, food security, and access to transportation, all of which are factors that CMS recognizes contribute to an individual’s overall health.  

This proposal aims to better identify and address the risk factors that may inhibit beneficiaries from accessing care and achieving optimal health outcomes and independence.

Stay tuned to ASCO in Action for cancer policy updates and to read comments ASCO plans to submit in response to the proposed rule.