CMS Issues New Policies to Provide Greater Transparency for Medicare Advantage and Part D Plans

The Centres for Medicare and Medicaid Services (CMS) are coming up with new policies to bring reforms in the healthcare industry. It is heralded as the final rule which aims at providing improved and better transparency for Medicare Advantage and Part D plans.

The new policies of the 2023 Medicare Advantage and Part D plans Final Rule push for affordable healthcare by reducing out-of-pocket charges for prescription drugs. However, that advantage will be in effect from 2024.

What Does The New CMS Policy Do?

The Biden – Harris administration has been committed to offering healthcare for all with quality and affordable care packages and this Final Rule is the extension of that. In fact, different areas have been worked on in the new CMS policy. Some of them are:

Price Negotiation

The finalized policy of CMS has made it mandatory for all Part D plans to apply concessions on the prices of the medicine that they receive from the network of pharmacies. The prices have to be negotiated at the point of sale. The policy will thus reflect in beneficiaries having the ability to share the savings. The process also boosts price transparency during the competition in the market for the program of Part D.

The CMS is working to redefine the negotiated price, which will be the baseline, or offer the lowest possible payment, which will be effective from January 1, 2024.

Uninterrupted Service

The new rule also states that policies will allow beneficiaries enrolled under the MA plans to have uninterrupted access to the necessary services during emergencies and disasters. It also covers areas like the COVID-19 pandemic.

Marketing Standards Revised

The policy also revises the requirements in marketing. It aims at strengthening the grip on third-party organizations that often engage in misleading activities. Part of the process thus includes implementing network adequacy standards, and MA applicants are required to show the network of the contracted providers. Only then will the CMS approve the application for the beneficiaries to expand or have a new contract.

New Standards For Application

The final rule also adds different categories under which the CMS can deny an application or any service expansion application. Some of the companies’ compliances are a Star rating of over 2.5, filing for bankruptcy, and failure to maintain the designated thresholds given for compliance.

Medical Loss Ratio Reporting

CMS is reinstating the loss ratio reporting to promote sustainability in the Medicare program. The feature also re-establishes the expansion of the reporting requirements for MA to receive additional advantages. The whole feature will improve the transparency of the Medicare advantage for Part D and MA plans’ and the underlying costs, which will benefit both the taxpayers and the beneficiaries. The medical loss ratio reporting was initially implemented in 2014 and lasted till 2017. The plan now requires detailed reporting on the amount that has been spent on the different supplemental benefits that were not available in the original Medicare.


The new policy also requires CMS to finalize the technical aspect of calculating the 2023 Part C Star Ratings. It will allow them to collect the necessary data, which is done through three different Healthcare Effectiveness Data and Information Set (HEDIS). HEDIS collects the data from the Health Outcome Survey: Monitoring Physical Activity, Bladder Control and Reducing the Risk of Falling.

Several other rules and changes that were put in as the interim final rule during the COVID-19 pandemic are also being reanalyzed and finalized since there was a disruption in the data collection. The interim final rule was in 2021 -2022.

Improved Coordination Between CMS & State

The policies implemented in the final rule allow better coordination between CMS and the states. It also will enable CMS to serve individuals better who have dual eligibility in Medicaid and Medicare. Hence, the process needs to have a different codifying system that can integrate materials and plans where dual eligibility is offered. In addition, the program must provide full scope to the individual having dual eligibility for Medicaid and Medicare benefits.

Annual MA Assessment

Additionally, the new rule makes all MA special needs plans assessed annually. It will allow them to identify the social risk factors for the individuals enrolled and their social needs. The process is believed to be a crucial step in offering person-centred care.

Why Do The New Policy Changes Matter?

CMS released the new rule on the day the Office of Inspector General released an unflattering report on prior authorization denials by Medicare Advantage. The report stated that there had been a constant denial of payment for services that met the coverage rules of Medicare and the MAO billing.

As part of the process now, the government with the new rule wants to have a detailed understanding and report on where MA plans are using the government money. Therefore, the rules are re-established for better transparency and improved support that can be given to the social determinants of health.

It is believed that many dually eligible individuals are at much higher risk of failing to have the security of housing, food, access to transportation, and health literacy. In addition, since the work of CMS is fiscal stewardship, it needs to know where the Medicare money is used and on which Medicare Advantage benefits.

The Final Rule has been implemented with this hope and the ability to close the health disparities gap with person-centred care. The policy aims to improve the health outcomes of the individuals enrolled by ensuring 100% reimbursement of the services availed by them. As these changes have direct impact on your medical billing and coding tasks, so it is crucial to know more about it with effect on your practice. Get in touch with your outsourced medical billing partner, i.e., 24/7 Medical Billing Services to know in detail.

Read more: Impact Of Medical Billing Audits On Your Practice

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