by Kristin Rowan | Dec 12, 2025 | Advocacy, CMS, Medicaid, Medicare, Medicare Advantage, Regulatory
CMS is making changes across Medicare and Medicare Advantage. From Star Ratings to Prescription Drug Prices to the Hospice benefit, CMS is embracing Make America Healthy Again. Will these initiatives benefit Medicare and Medicare Advantage recipients or the insurance companies who provide the plans?
In early November, CMS announced a plan to lower prescription drug costs for Medicaid recipients. State Medicaid programs can opt in to the GENErating cost Reductions fOr U.S. Medicaid Model (GENEROUS). The pilot program is using the most-favored-nation pricing that was recently negotiated and announced by President Trump. Most-favored-nation pricing requires prescription drug manufacturers to charge the same low rate paid in other countries.
Beginning in 2026, CMS will negotiate with manufacturers of select drugs for lower pricing. Participating states will start using uniform, transparent coverage criteria. This is not criteria for inital coverage in Medicaid, but for standardizing access to high-cost medications.
Manufacturers are not required to participate in the GENEROUS Model, but can voluntarily apply. Participating manufacturers agree NOT to seek additional supplemental rebates or discounts outside the model price.
New Medicare Advantage Policies
CMS has proposed updates to the Medicare Advantage and Medicare Part D programs. The new plan would begin in CY 2027 and includes major changes to the Star Ratings system. CMS is also seeking feedback on new ways to modernize MA.
The proposed changes are supposed to incentivize plans to improve care. CMS suggests removing 12 unique measures that look at administrative processes and those that don’t highlight differences between plans. Star Rating measurements of care, outcomes, and patient experience will remain.
CMS is seeking feedback on Medicare Advantage changes, including improving competition, refining risk adjustment, and aligning quality incentives to deliver greater value. CMS is open to either a limited model test or program-wide changes. Interested parties can submit feedback through January 26, 2026. Read the Proposed Rule here. Submit your comments.
Expanding Technology-Enabled Care
CMS may finally be recognizing what we’ve been promoting for 25 years: Care improves with technology support.
The ACCESS model tests a new payment approach in original Medicare to expand access to technology-supported care options. CMS aims to increase technology-supported care options to improve health and prevent and manage chronic diseases. More than two-thirds of Medicare beneficiaries are dealing with high blood pressure, diabetes, chronic musculoskeletal pain, and depression.
An interest form is now available for the 10-year Advancing Chronic Care with Effective, Scalable Solutions (ACCESS) Model test. The model test begins July 1, 2026. The application to participate must be received by April 1, 2026.
As these programs roll out between now and 2029, the impact on insurance plans, payors, beneficiaries, and taxpayers will unfold. Will lower cost prescriptions and technology-based care lower insurance rates? Payor reform may be necessary to change out-of-pocket costs. Regulations may have to further incentivize payors to increase care when costs go down, particularly with value-based care models.
Please take a few minutes to read the details on each of these proposals, add your comments, and sign up to participate. The industry needs reform and our aging family members deserve better.
Kristin Rowan has been working at The Rowan Report since 2008. She is the owner and Editor-in-chief of The Rowan Report, the industry’s most trusted source for care at home news, and speaker on Artificial Intelligence and Lone Worker Safety and state and national conferences.
She also runs Girard Marketing Group, a multi-faceted boutique marketing firm specializing in content creation, social media management, and event marketing. Connect with Kristin directly kristin@girardmarketinggroup.com or www.girardmarketinggroup.com
©2025 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com
by Kristin Rowan | Feb 14, 2025 | Admin, Regulatory
CMS 2026 Updates to Prescription Plan
The Centers for Medicare & Medicaid Services (CMS), as part of the Inflation Reduction Act of 2022 (IRA), released a draft of the calendar year 2026 redesign program instructions. The new provisions for Medicare Part D include:
- An annual out-of-pocket maximum of $2,100, up from $2,000 in 2025
- A selected drug subsidy program
- The requirement that Part D plans offer enrollees the option to spread out their out-of-pocket costs over the year
- Maximum charge of $35 for insulin regardless of deductible, co-pay, or out-of-pocket spending reached
- No out-of-pocket costs for recommended vaccines
- New requirements for Creditable Coverage
Current Creditable Coverage Determination
The current simplified determinations method is as follows:
- The plan provides coverage for brand and generic prescriptions;
- The plan provides reasonable access to retail providers;
- The plan is designed to pay on average at least 60% of participants’ prescription drug expenses; and
- The plan satisfies at least one of the following:
- The coverage has no annual benefit maximum or maximum annual benefit payable by the plan of at least $25,000;
- The coverage has an actuarial expectation that the amount payable by the plan will be at least $2,000 annually per Medicare-eligible individual; or
- For employer plan sponsors that have integrated prescription drug and health coverage, the integrated plan has no more than a $250 deductible per year, has no annual benefit maximum or a maximum annual benefit of at least $25,000, and has no less than a $1,000,000 lifetime combined benefit maximum.
Medicare beneficiaries must enroll in Medicare Part D, unless they have other prescription coverage. If a beneficiary goes more than 63 days without prescription coverage, they may incur a late enrollment penalty. Creditable coverage has to have a value equal to or greater than the defined coverage for Part D. This requirement is not new. Group health plans have been calculating creditable coverage since the inception of the Part D program. What is new is that CMS has determined that the simplified method of determining creditable coverage is no longer accurate. The revised method must include all of the following:
- Provide reasonable coverage for brand name and generic prescription drugs and biological products
- Provide reasonable access to retail pharmacies
- Is designed to pay on average at least 72% of participants’ prescription drug expenses
Persons over the age of 65 who qualify for Medicare, but who are still employed may have an employer sponsored or paid health insurance plan. Many of these plans have combined health and drug coverage. These plans will now have to provide creditable coverage, presumably for all beneficiaries, not just those who are eligible for Medicare.
- The coverage has no annual benefit maximum or maximum annual benefit payable by the plan of at least $25,000;
- The coverage has an actuarial expectation that the amount payable by the plan will be at least $2,000 annually per Medicare-eligible individual; or
- For employer plan sponsors that have integrated prescription drug and health coverage, the integrated plan has no more than a $250 deductible per year, has no annual benefit maximum or a maximum annual benefit of at least $25,000, and has no less than a $1,000,000 lifetime combined benefit maximum.
For Additional Information
If you are currently offering an employee sponsored health plan, or need more information on Part D coverage, refer to the CMS Fact Sheet and the Program Instructions.
Kristin Rowan has been working at The Rowan Report since 2008. She is the owner and Editor-in-chief of The Rowan Report, the industry’s most trusted source for care at home news .She also has a master’s degree in business administration and marketing and runs Girard Marketing Group, a multi-faceted boutique marketing firm specializing in content creation, social media management, and event marketing. Connect with Kristin directly kristin@girardmarketinggroup.com or www.girardmarketinggroup.com
©2025 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com
by Rowan Report | Dec 13, 2023 | CMS, Regulatory
From the NAHC Newsroom
Public comments due January 5, 2024
CMS Policy Changes to Medicare C & D. On November 5, 2023, the Centers for Medicare & Medicaid Services (CMS) issued the Contract Year 2025 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicare Cost Plan Program, and Programs of All-Inclusive Care for the Elderly; Health Information Technology Standards and Implementation Specifications.
Key provisions in the CMS policy changes that are of interest to home health and hospice providers are detailed below.
Behavior Health
CMS aims to improve access to behavioral health care by adding certain behavioral health provider specialties to the MA network adequacy standards as a new facility-specialty type. The new facility-specialty type, ‘‘Outpatient Behavioral Health,’’ can include Marriage and Family Therapists (MFTs), Mental Health Counselors (MHCs), Opioid Treatment Program (OTP) providers, Community Mental Health Centers or other behavioral health and addiction medicine specialists and facilities.
Special Supplemental Benefits for the Chronically Ill (SSBCI)
CMS is proposing regulatory changes that would help ensure that SSBCI items and services offered are appropriate and improve or maintain the health or overall function of chronically ill enrollees. The MA organization must be able to demonstrate through relevant acceptable evidence that an item or service offered as SSBCI has a reasonable expectation of improving or to maintain the health or overall function of a chronically ill. The MA plan must follow its written policies based on objective criteria for determining an enrollee’s eligibility for an SSBCI when making such eligibility determinations. CMS is proposing to require that the MA plan document its denials of SSBCI eligibility rather than its approvals.
CMS will also modify and strengthen the current requirements for the SSBCI disclaimer that MA organizations offering SSBCI must use whenever SSBCI are mentioned. Additionally, CMS proposes to require MA plans to notify enrollees mid-year of the unused supplemental benefits available to them. The notice would list any supplemental benefits not utilized by the beneficiary during the first 6 months of the year.
Guardrails for Agent and Broker Compensation
CMS is proposing to generally prohibit contract terms between MA organizations and agents, brokers or other third party marketing organizations (TPMOs) that may interfere with the agent’s or broker’s ability to objectively assess and recommend the plan that best fits a beneficiary’s health care needs, CMS proposes to set a single compensation rate for all plans; revise the scope of items and services included within agent and broker compensation; and eliminate the regulatory framework which currently allows for separate payment to agents and brokers for administrative services. CMS also intends to make similar changes to the Part D agent broker compensation rules.
Health Equity and Utilization Management (UM)
CMS proposes to require that a member of the UM committee have expertise in health equity and that t the UM committee conduct an annual health equity analysis of the use of prior authorization. The analysis would examine the impact of prior authorization on enrollees with one or more of the following social risk factors (SRFs): receipt of the lowincome subsidy or being dually eligible for Medicare and Medicaid (LIS/DE); or having a disability.
Right To Appeal an MA Plan’s Decision To Terminate Coverage for Non-Hospital Provider Services
Beneficiaries enrolled in Traditional Medicare and MA plans have the right to a fast-track appeal by an Independent Review Entity (IRE) when their covered skilled nursing facility (SNF), home health, or comprehensive outpatient rehabilitation facility (CORF) services are being terminated. Currently, Quality Improvement Organizations (QIO) act as the IRE and conduct these reviews. Under current regulations, MA enrollees do not have the same access to QIO review of a fast-track appeal as Traditional Medicare beneficiaries. CMS proposes to (1) require the QIO, instead of the MA plan, to review untimely fast-track appeals of an MA plan’s decision to terminate services in an HHA, CORF, or SNF; and (2) fully eliminate a provision that requires the forfeiture of an enrollee’s right to appeal a termination of services decision when they leave the facility. These proposals would bring MA regulations in line with the parallel reviews available to beneficiaries in Traditional Medicare and expand the rights of MA beneficiaries to access the fast-track appeals process.
- Dual eligible Special Needs Plans (D-SNP)
- CMS proposes to increase the percentage of dually eligible managed care enrollees who receive Medicare and Medicaid services from the same organization.
- CMS is also proposing to limit out-of-network cost sharing for D–SNP preferred provider organizations (PPOs) for specific services.
Further, CMS is proposing to lower the D–SNP look-alike threshold from 80 percent to 70 percent for plan year 2025 and 60 percent for plan year 2026. This proposal would help address the continued proliferation of MA plans that are serving high percentages of dually eligible individuals without meeting the requirements to be a D–SNP.
The National Association for Home Care and Hospice will continue to analyze the proposed rule, but supports CMS’ aim to protect Medicare beneficiaries by modifying policies and procedures that will improve programs under Part C and Part D.
Public comments are due January 5, 2024.
This article originally appeared at https://nahc.org/cms-proposes-policy-changes-to-medicare-part-c-and-part-d/. All rights reserved.
