Two Proposed Rules Could Significantly Impact Stakeholders in Federal Health Care Programs

In the last month, two new proposed rules were introduced that will impact stakeholders in federal health care programs, including the Affordable Care Act (ACA) and Medicare. Here are the highlights.

Contract Year 2023 Medicare Advantage and Part D Proposed Rule

On January 6, 2023, the Centers for Medicare & Medicaid Services (CMS) released a proposed rule for the 2023 Medicare Advantage (MA) and Part D plan year. According to CMS, the proposed rule would “lower out of pocket Medicare Part D prescription drug costs and improve consumer protections, reduce disparities, and improve health equity” in MA and Part D. Some of the proposed changes include:

• Requiring Part D plans to apply all price concessions received from network pharmacies to the point of sale by redefining the “negotiated price” for Part D plans as “the lowest amount a pharmacy could receive as reimbursement for a covered Part D drug under its contract with the Part D plan sponsor or the sponsor's intermediary.”
• Requiring MA plans to comply with special access to care requirements when there is a declaration of disaster or emergency that also contributes to a disruption in access to health care.
• Requiring that MA plan applicants to demonstrate network adequacy as part of the MA application process for new and expanding service areas.
• Requiring all special needs plans to include standardized questions on housing stability, food security, and access to transportation as part of their health risk assessments.

The proposed rule was published in the Federal Register on January 12, 2022 and comments may be submitted through March 7, 2022.

HHS Notice of Benefit and Payment Parameters for 2023 Proposed Rule

The U.S. Department of Health and Human Services (HHS) issued a proposed rule for the 2023 plan year for ACA Exchanges and the individual and group health insurance markets on December 28, 2021. According to CMS, the proposed rule “minimizes the number of significant regulatory changes to provide states and issuers with a more stable and predictable regulatory framework that facilitates a more efficient and competitive market.” The following are among the changes proposed:

• During the qualified health plan (QHP) certification process, CMS proposes to evaluate network adequacy in all Federally facilitated Exchange (FFE) states, except those states that perform plan management functions and elect to perform their own reviews, provided that such states meet the minimum federal standards and perform their reviews prior to QHP certification.
• Requiring issuers in FFEs and state-based exchanges on the federal platform to offer standardized plan options at every product network type, metal level and throughout every service area that they offer non-standardized option in plan year 2023.
• Restoring protections against discrimination on the basis of sexual orientation or gender identity.
• Specifying that quality improvement activity expenses for medical loss ratio reporting and rebate calculation purposes are limited to those expenses directly related to activities that improve health care quality.

The proposed rule was published in the Federal Register on January 5, 2022 and was open for comments through January 27, 2022.