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CMS recently published the CY 2027 Medicare Advantage (MA) and Part D proposed rule, which includes a broad set of policy, operational, and programmatic changes with implications for rheumatology practices and patients. The proposal includes regulatory amendments to codify Inflation Reduction Act (IRA) policies implemented through program instructions, including the CY 2025 and CY 2026 Part D redesign and Manufacturer Discount Program guidance, along with related technical corrections affecting the Part D benefit, coverage gap, and manufacturer discount programs.
For MA and Part D operations, CMS proposes to streamline and rename the Special Enrollment Period (SEP) for provider terminations and to clarify which SEPs require CMS approval, an issue of particular concern for rheumatology given ongoing network adequacy challenges and recent terminations of rheumatologists from MA networks. CMS also proposes changes affecting enrollment and marketing oversight, including new disclaimer requirements for third-party marketing organizations (TPMOs), eliminating certain marketing time and manner restrictions, and relaxing certain advertising language requirements, all of which raise questions about how beneficiary protections will be maintained.
The rule also proposes significant changes to the Star Ratings program, including removal of 12 operational, process, and patient experience measures - notably Complaints about the Health/Drug Plan and important appeals-related measures (i.e., Plan Makes Timely Decisions about Appeals and Reviewing Appeals Decisions). These measures have historically served as important tools to identify access barriers, inappropriate denials, and misleading marketing practices affecting beneficiaries.
Additional proposals include changes aimed at reducing regulatory burden, revisions to utilization management and quality improvement requirements, codification of opioid outlier prescriber provisions under the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act, and clarifications related to Special Supplemental Benefits for the Chronically Ill (SSBCI). CMS also seeks public input through multiple requests for information (RFIs) on risk adjustment, quality bonus payments, dual-eligible enrollment growth, well-being and nutrition, and plan marketing practices, including network adequacy and supplemental benefit utilization, providing key opportunities for the rheumatology community to reiterate longstanding access and oversight concerns.
Additional details are available in CMS’ fact sheet on the proposed rule. CSRO is preparing formal comments on the rule and seeks input from state societies and rheumatology practices, including examples of how MA and Part D policies are affecting rheumatology practices and patient access to care. Please share experiences by January 2 so they can be incorporated, as appropriate, into CSRO’s written response.
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