Annual Election Period (AEP) is about two weeks away when Medicare Advantage Prescription Drug Plans (MAPD) will be signing up new enrollees by the thousands. According to the Centers for Medicare & Medicaid Services (CMS), enrollment in MAPD keeps rising. In 2022, 48% of all eligible Medicare beneficiaries are enrolled in MAPD. And, in 2023, there will be more enrollees in MAPD than in original Medicare.

Medicare Advantage Organizations (MAO) not only have to get ready for newcomers, they also have to implement changes in the MA program that are not waiting to become effective on January 1, 2023; some are happening or have already begun!

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On July 21, 2022, CMS announced that, in collaboration with the Plan Program Integrity Medicare Drug Integrity Contractor (PPI MEDIC), CMS will initiate several National Audits, Self-Audits, and Program Integrity (PI) Audits beginning October 2022 and continuing throughout 2023. The purpose of these audits is to evaluate a plan sponsor’s efforts to prevent, detect, and correct fraud, waste, and abuse (FWA) in the Medicare Part C and Part D programs. Plan sponsors will be notified in advance of the upcoming audit schedule and targeted universes under review for each audit type.

New third-party marketing organization (TPMO) oversight requirements will go into effect on October 1, 2022. MAOs have to ensure that TPMOs use a standardized disclaimer in their marketing materials that meet the definition of marketing whether they are in print, on the website, or in television advertising. Plan sponsors also need to ensure TPMO’s adherence with these requirements through contractual arrangements, review of materials, or other appropriate oversight methods available to the MAO or Part D sponsor, such as complaint reviews or audits. Agents and brokers have to record all calls with beneficiaries in their entirety, including the enrollment process beginning October 1, 2022.

On September 9, 2022, CMS reminded MAOs and drug plan sponsors of the new benefits pursuant to the Inflation Reduction Act (IRA) 2022, beginning on or after January 1, 2023. For adult vaccines recommended by the Advisory Committee on Immunization Practices (ACIP), the deductible shall not apply, and there is no cost sharing. Adult vaccine recommended by ACIP is a covered Part D drug when licensed by the US Food and Drug Administration (FDA) under the Public Health Service Act for use by adult populations and administered in accordance with recommendations of ACIP. Applicable Part D vaccines should have no cost sharing or any associated sales tax, dispensing fee, or vaccine administration fee, regardless of tier placement or benefit phase.

The ACIP issues a new vaccine recommendation for adults quarterly during the plan year. Part D sponsors are required to provide any newly recommended vaccines to adult enrollees as Part D benefits.

Another highly anticipated change to begin on January 1, 2023 pursuant to the IRA is the $35 cap per month on out-of-pocket costs to Medicare beneficiaries. If MAOs cannot implement this benefit between January 1 and March 31, 2023, they can reimburse their enrollees for the amounts exceeding $35 a month. However, such allowance is not extended beyond March 31, 2023.

The $35 monthly cap is applicable to “insulin product,” which includes combination products containing more than one type of insulin, and combination products that contain both insulin and a non-insulin drug or biological product.

CMS is granting a Special Enrollment Period (SEP) for Exceptional Circumstances to allow beneficiaries to add, drop, or change their Part D coverage, if they find a better option after the 2022 AEP and through the end of 2023. This SEP will be available for all beneficiaries who use a covered insulin product, and begins on December 8th, 2022 and ends on December 31, 2023. Beneficiaries may use this SEP one time during this period.  

The above IRA-related items are “hot off the press” announcements in September 2022, prior to which, previously announced changes in final rule CMS 4192 F for 2023 include (but are not limited to):

  • Offering real-time comparison tools to enrollees so they have access to real-time formulary and benefit information — including cost-sharing — to shop for lower-cost alternative therapies under their prescription drug benefit plan
  • Maximum out-of-pocket (MOOP) expenses for Parts A and B services will be calculated on accrual for beneficiaries with secondary insurance notably dual eligible beneficiaries
  • Any MAO offering a D-SNP (Dual Special Needs Plan) must establish one or more enrollee advisory committee(s) in each state to solicit direct input on enrollee experiences. The advisory committee must solicit input on ways to improve access to covered services, coordination of services, and health equity among underserved populations
  • Return of the multi-Language Insert to CMS required materials such as the Summary of Benefits (SB), Annual Notice of Change (ANOC)/Evidence of Coverage (EOC), and the enrollment form that have to be submitted to CMS by September 30, 2022 regardless of the five percent service area threshold
  • Current public health emergency may end on October 12, 2022; special requirements for the duration of disasters and emergencies where access to covered benefits is disrupted will continue in 2023.

If you need help to monitor and audit effective compliance with the above and other regulatory changes to the Medicare Advantage program in 2023, we, at Inovaare, can provide technical and consulting resources through special applications and multi-years of hands-on experience in supporting MAPD clients. If you have any questions, or you’d like to discuss these changes with one of our compliance experts, please call us at 1.408.850.2235. or Contact Us.