Medicare proposes rule to fix plan directories and rein in PBMs
Medicare officials proposed a rule requiring Medicare Advantage plans to check their doctor directories at least every 90 days, Healthcare Dive and Fierce Healthcare reported. Seniors misled by a wrong listing would pay only in-network costs. The rule would also change how drug middlemen are paid.
The Centers for Medicare and Medicaid Services on Friday proposed a rule to make Medicare Advantage provider directories more accurate and to change how pharmacy benefit managers are paid, Healthcare Dive and Fierce Healthcare reported.
The rule would require Medicare Advantage plans to check that their provider directories are accurate, and fix them if not, at least once every 90 days, Healthcare Dive and Fierce Healthcare reported. Seniors who see an out-of-network provider because a directory wrongly listed them as in-network would pay no more than in-network cost sharing, Healthcare Dive and Fierce Healthcare reported.
Plans would also have to report directory accuracy scores, Healthcare Dive reported. The 90-day reviews and cost-sharing protections would take effect in 2028, and public display of accuracy scores would follow in 2029, Healthcare Dive and Fierce Healthcare reported. The changes aim to give the 36 million seniors in Medicare Advantage more reliable information on which doctors and hospitals are covered, Healthcare Dive reported. A 2018 CMS review found directory error rates from 5% to 93% depending on the plan, Healthcare Dive reported.
For pharmacy benefit managers, the drug middlemen, the rule would limit them to flat service fees that cannot be based on a drug's price or the rebates it generates, Healthcare Dive reported. Their pay would have to reflect "fair market value for services provided, rather than drug costs," Fierce Healthcare reported. They would also have to pass rebates through to Part D plans and file annual reports on their pay and decisions, Healthcare Dive reported.
The rule would also cut generic drug copays for low-income seniors who qualify for both Medicare and Medicaid from $1 to $0, Healthcare Dive and Fierce Healthcare reported. Fierce Healthcare reported that change would begin January 1.
"CMS has been working to improve data connectivity and accuracy in provider directories across the healthcare system," CMS Administrator Mehmet Oz said, according to Healthcare Dive and Fierce Healthcare.
The proposals carry out provisions of a government funding law signed in February, Healthcare Dive and Fierce Healthcare reported. CMS said the directory rules will raise compliance costs for plans, Fierce Healthcare reported.
What we know: CMS has proposed 90-day directory checks, cost protections for seniors and new pay limits for PBMs.
What we don't: What the PBM changes will cost, which CMS says it cannot yet estimate, and what the final rule will look like.
Where outlets agree Healthcare Dive and Fierce Healthcare report that CMS proposed 90-day directory checks for Medicare Advantage plans, in-network cost protections and new limits on PBM pay.
Where they differ The outlets cited here report the same key facts so far.