Doing this here for others but also so I force myself to actually read the synopsis. These are my notes for normal people. A couple of things are critical to agents and they are noted.
1. Vaccines don't apply to the Part D Deductible. (OK? What else is new and why do we need this?)
2. Insulin doesn't apply to the deductible and they are adding drugs to the $35 list. Clarification if an RX is more than 30 days but less than $60 and how its paid.
3. Clarification on PPP rules
4. Coverage of the weight loss drugs. Get ready. $34 Billion to the Trust Fund over 10 years.
5. Provider Directories better be right when sent to Medicare for the Plan Finder
6. Promoting Informed Choice—Expand Agent and Broker Requirements Regarding Medicare Savings Programs, Extra Help, and Medigap
To ensure beneficiaries are well informed about and have an accurate picture of their MA and Part D enrollment options, we are also proposing to add the following topics to the existing list of requirements that agents and brokers must discuss with their customers: the availability of low-income supports including the Part D Low-Income Subsidy (also known as "Extra Help") and Medicare Savings Programs; for beneficiaries enrolling into MA when first eligible for Medicare or dropping a Medigap plan to enroll in an MA plan for the first time, general information on Medigap Federal guaranteed issue (GI) rights, the practical implications of switching from Medicare Advantage to Traditional Medicare, and, when applicable, provide information on state laws regarding Medigap GI rights for those states where the agent or broker is licensed and appointed to sell; and requiring that agents pause to address remaining questions the beneficiary may have related to enrollment in a plan prior to moving forward with an enrollment. As Medicare enrollees consider their coverage options, it is essential that agents and brokers provide adequate information to ensure beneficiaries can make fully informed choices, both to support enrollees and promote a functioning, competitive marketplace.
(I'm in love with whoever put this in there. This one is AWESOME!)
7. All Marketing and Communication gets approved by CMS and not the carriers.
8. Pharmacy Networks need to be accurate on 10/1, not 1/1.
9. MAPD Supplemental benefits need to be done via debit card
10. Improves access to internal coverage criteria. (I'm not sure I even know what this is!)
11. They want more Mental Health coverage and in network providers. (Someone needs to tell CMS that its not the carriers, its the providers refusing to be part of networks)
12. Better integration for dual eligible enrollees
13. Medical Loss Ratio (MLR)
To improve medical loss ratio (MLR) reporting and oversight and to better align MA and Part D MLR requirements with commercial MLR and Medicaid MLR requirements, we are proposing to make certain changes to the regulations that govern MLR requirements for MA and Part D. Specifically, we are proposing to establish clinical and quality improvement standards for provider incentives and bonus arrangements included in the MA MLR numerator in order to help align such bonus payments with care outcomes and avoid excess premium transfer to providers. We also propose to prohibit administrative costs from being included in quality improvement activities in both the MA and Part D MLR numerator. Additionally, we propose to adopt additional requirements for the allocation of expenses in the MLR. We also propose to establish new audit and appeals processes for MLR compliance. In addition, we propose to amend the Medicare MLR regulations authorizing the release of Part C and Part D MLR data. We propose to codify the rules we established in the CY 2025 Part D Redesign Program Instructions for the treatment for MLR purposes of Medicare Prescription Payment Plan unsettled balances for 2026 and subsequent years. We also propose to explicitly provide that the Medicare MLR reporting include detailed information regarding provider payment arrangements. In addition to the proposed changes, we are issuing a request for information on potential policies that CMS could adopt regarding how the MA and Part D MLRs are calculated in order to enable policymakers to address concerns surrounding vertical integration in MA and Part D.
OH I REMEMBER WHAT HAPPENED ON 3/23/2010 when commission on individual plans was included in the MLR. We took a massive commission hit. NABIP better step up to the plate on this one. They rolled over on ACA and this is when they can really make a difference.
14. Network pharmacies are included in the Pricing Negotiation
15. Annual Health Equity Analysis of Utilization Management Policies and Procedures. They want to revise the metrics on prior auth's. So that's nice.
16. Guardrails for using AI
17. Including non- doctors in provider directories. Example: you have a transportation benefit, the provider for the transportation has to be included in the directory
1. Vaccines don't apply to the Part D Deductible. (OK? What else is new and why do we need this?)
2. Insulin doesn't apply to the deductible and they are adding drugs to the $35 list. Clarification if an RX is more than 30 days but less than $60 and how its paid.
3. Clarification on PPP rules
4. Coverage of the weight loss drugs. Get ready. $34 Billion to the Trust Fund over 10 years.
5. Provider Directories better be right when sent to Medicare for the Plan Finder
6. Promoting Informed Choice—Expand Agent and Broker Requirements Regarding Medicare Savings Programs, Extra Help, and Medigap
To ensure beneficiaries are well informed about and have an accurate picture of their MA and Part D enrollment options, we are also proposing to add the following topics to the existing list of requirements that agents and brokers must discuss with their customers: the availability of low-income supports including the Part D Low-Income Subsidy (also known as "Extra Help") and Medicare Savings Programs; for beneficiaries enrolling into MA when first eligible for Medicare or dropping a Medigap plan to enroll in an MA plan for the first time, general information on Medigap Federal guaranteed issue (GI) rights, the practical implications of switching from Medicare Advantage to Traditional Medicare, and, when applicable, provide information on state laws regarding Medigap GI rights for those states where the agent or broker is licensed and appointed to sell; and requiring that agents pause to address remaining questions the beneficiary may have related to enrollment in a plan prior to moving forward with an enrollment. As Medicare enrollees consider their coverage options, it is essential that agents and brokers provide adequate information to ensure beneficiaries can make fully informed choices, both to support enrollees and promote a functioning, competitive marketplace.
(I'm in love with whoever put this in there. This one is AWESOME!)
7. All Marketing and Communication gets approved by CMS and not the carriers.
8. Pharmacy Networks need to be accurate on 10/1, not 1/1.
9. MAPD Supplemental benefits need to be done via debit card
10. Improves access to internal coverage criteria. (I'm not sure I even know what this is!)
11. They want more Mental Health coverage and in network providers. (Someone needs to tell CMS that its not the carriers, its the providers refusing to be part of networks)
12. Better integration for dual eligible enrollees
13. Medical Loss Ratio (MLR)
To improve medical loss ratio (MLR) reporting and oversight and to better align MA and Part D MLR requirements with commercial MLR and Medicaid MLR requirements, we are proposing to make certain changes to the regulations that govern MLR requirements for MA and Part D. Specifically, we are proposing to establish clinical and quality improvement standards for provider incentives and bonus arrangements included in the MA MLR numerator in order to help align such bonus payments with care outcomes and avoid excess premium transfer to providers. We also propose to prohibit administrative costs from being included in quality improvement activities in both the MA and Part D MLR numerator. Additionally, we propose to adopt additional requirements for the allocation of expenses in the MLR. We also propose to establish new audit and appeals processes for MLR compliance. In addition, we propose to amend the Medicare MLR regulations authorizing the release of Part C and Part D MLR data. We propose to codify the rules we established in the CY 2025 Part D Redesign Program Instructions for the treatment for MLR purposes of Medicare Prescription Payment Plan unsettled balances for 2026 and subsequent years. We also propose to explicitly provide that the Medicare MLR reporting include detailed information regarding provider payment arrangements. In addition to the proposed changes, we are issuing a request for information on potential policies that CMS could adopt regarding how the MA and Part D MLRs are calculated in order to enable policymakers to address concerns surrounding vertical integration in MA and Part D.
OH I REMEMBER WHAT HAPPENED ON 3/23/2010 when commission on individual plans was included in the MLR. We took a massive commission hit. NABIP better step up to the plate on this one. They rolled over on ACA and this is when they can really make a difference.
14. Network pharmacies are included in the Pricing Negotiation
15. Annual Health Equity Analysis of Utilization Management Policies and Procedures. They want to revise the metrics on prior auth's. So that's nice.
16. Guardrails for using AI
17. Including non- doctors in provider directories. Example: you have a transportation benefit, the provider for the transportation has to be included in the directory
