CMS Proposes Rule to Lower Out of Pocket Prescription Drug Costs

Written by Shelby Hudson

January 7, 2022

On January 6, 2021, the Centers for Medicare & Medicaid Services (CMS) proposed a rule to update the Medicare Advantage (MA) & Medicare Part D programs.This rule aims to improve the health equity & out-of-pocket costs of those enrolled in Medicare Advantage and Part D plans.

This rule will aim to lower out-of-pocket drug costs for beneficiaries enrolled in Medicare Part D and improve price transparency & market competition. It would ensure that price concessions (arrangements between pharmacies & Part D Plans where plans pay less money to pharmacies for dispensed drugs if the pharmacies do not meet specific metrics) are applied at the points of sale. This would take effect on January 1, 2023, effectively reducing out-of-pocket costs for beneficiaries.

This rule also would improve the experiences of those beneficiaries enrolled in MA & Part D, especially those who are dual-eligible for Medicare & Medicaid. As a whole, CMS is trying to hold MA & Part D plans to a higher standard to improve health equity. The rule is looking to ensure that people’s experiences in both Medicare & Medicaid are considered in decision making for those enrolled in Dual Special Needs Plans (D-SNPs) offered by MA companies that enroll individuals in both Medicare & Medicaid. This rule would establish enrollee advisory committees that MA companies who offer D-SNP plans would have to consult for decision-making.

CMS is also looking to strengthen its oversight on 3rd party MA marketing to ensure that all people will Medicare receive accurate and accessible information about Medicare coverage. This includes information in all marketing about the availability of free translation services.

For CMS’s fact sheet on the proposed rule, click here to learn more: https://www.cms.gov/newsroom/fact-sheets/cy-2023-medicare-advantage-and-part-d-proposed-rule-cms-4192-p

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