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Proposed Changes to Medicare Advantage and Part D

Proposed Changes to Medicare Advantage and Part D

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The Centers for Medicare & Medicaid Services (CMS) issued a proposed rule and the Advance Notice Part II to further advance the agency's efforts to strengthen and modernize the Medicare Advantage and Part D prescription drug programs.

Short Notes:

  • The changes proposed would lower beneficiary cost sharing on some of the most expensive prescription drugs, promote the use of generic drugs, and allow beneficiaries to know in advance and compare their out-of- pocket payments for different prescription drugs.
  • The proposed changes described in the Advance Notice are expected to increase plan revenue by 0.93%.
  • These new CMS proposals will improve the Medicare experience.
  • The proposed rule would require Part D plans to offer real-time drug price comparison tools to beneficiaries starting January 1, 2022, so consumers could shop for lower-cost alternative therapies under their prescription drug benefit plan.
  • It strengthens plans’ negotiating power with prescription drug manufacturers so American patients can get a better deal.
  • The proposed rule would allow a second, “preferred” specialty tier in Part D with a lower cost sharing amount.
  • The proposed rule would require Part D plans to disclose such information to enable CMS to track how plans are measuring and applying pharmacy performance measures.
  • One way to help lower drug prices for beneficiaries is to encourage greater use of lower price generics and biosimilars.
  • In the Advance Notice, CMS is seeking comment on potentially developing measures of generic and biosimilar utilization in Medicare Part D as part of a plan’s star rating.
  • Today’s proposed rule implements to give all beneficiaries with ESRD the option to enroll in a Medicare Advantage plan starting in 2021. This will give patients with ESRD access to more affordable Medicare coverage choices and extra benefits such as transportation or home- delivered meals.
  • CMS is proposing to build on the current benefits and give Medicare Advantage plans more flexibility to count telehealth providers in certain specialty areas like psychiatry, neurology, or cardiology towards network adequacy standards, which would encourage greater use of telehealth services as well as increase plan choices for beneficiaries.
  • These proposed changes aim to give seniors more plan choices in rural areas, increase competition between plans, and allow providers to take advantage of the latest healthcare technologies and innovations.
  • CMS is also proposing to enhance the Medicare Advantage and Part D Star Ratings to further increase the impact that patient experience and access measures have on a plan’s Star Rating.
  • The proposed rule implements several provisions that require Part D plans to educate beneficiaries on opioid risks, alternate pain treatments, and safe disposal of opioids. As well as, expands drug management programs and medication therapy management programs.

CMS looks forward to feedback on the proposed rule. Comments may be submitted electronically through our e-Regulation website at:

To submit comments or questions electronically, go to, enter the docket number “CMS-2020-0003” in the “search” field, and follow the instructions for ‘‘submitting a comment.’’

For a fact sheet on the CY 2021/2022 Medicare Advantage and Part D Proposed Rule (CMS- 4190-P), please visit:

The proposed rule can be downloaded

from the Federal Register at:


The 2021 Medicare Advantage and

Part D Advance Notice Part II Fact Sheet:

Medicare Advantage and Part D Advance Notice Part II, please visit: