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CMS Finalizes Program Changes for Medicare Advantage and Prescription Drug Benefit Programs for Contract Year 2015

The Centers for Medicare & Medicaid Services (CMS) issued final regulations (CMS-4159-F) for the Medicare Advantage and prescription drug benefit (Part D) programs that continue efforts to curb fraud and abuse and to improve benefits and the quality of care for seniors and people with disabilities enrolled in these programs. The final rule is projected to save an estimated $1.615 billion over the next ten years 2015 - 2024. To view a fact sheet on the final 2015 Part C and D rule, click here. To view CMS' response to hospice related comments, click here.

After careful consideration of over 7,500 public comments on a proposed rule displayed on January 6, 2014, key final provisions include:

  • Requiring Part D prescribers to enroll in Medicare: CMS is requiring that physicians and eligible professionals who prescribe covered Part D drugs be enrolled in Medicare, or have a valid record of opting out of Medicare, in order for their prescriptions to be covered under Part D. Requiring prescribers to enroll in Medicare would help CMS ensure that Part D drugs are only prescribed by qualified individuals. The final rule allows more time - until June 1, 2015 - for implementation.
  • Revoking Medicare enrollment for abusive prescribing practices and patterns: CMS will have the authority to revoke a physician or eligible professional's Medicare enrollment if CMS determines that he or she has a pattern or practice of prescribing that is abusive, represents a threat to the health and safety of Medicare beneficiaries, or otherwise fails to meet Medicare requirements. CMS will also be able to revoke a physician or eligible professional's Medicare enrollment if his or her Drug Enforcement Administration (DEA) Certificate of Registration is suspended or revoked, or if the applicable licensing or administrative body for any state in which he or she practices suspends or revokes his or her ability to prescribe drugs.
  • Expanded prevention and health improvement incentives: The final rule expands rewards and incentive programs that focus on encouraging participation in activities that promote improved health, efficient use of health care resources and prevent injuries and illness.
  • Broadening the release of privacy-protected Part D data: CMS will expand the release of unencrypted, prescriber, plan and pharmacy identifiers contained in prescription drug event records to give the public broader access to health care data pursuant to CMS' policies and procedures for release of such data while still preserving the privacy of Medicare beneficiaries.
  • Improving MA risk-adjustment data validation (RADV) audit appeals procedures: The rule strengthens RADV by streamlining the RADV audit appeals process by combining error rate calculation appeals and medical record review-determination appeals into one combined process. The streamlined process will reduce administrative burden on both MA plans and CMS.
  • Providing direct access to Part D sponsors' downstream entities: This provision will provide CMS, its antifraud contractors, and other oversight agencies the ability to request and collect information directly from pharmacy benefit managers, pharmacies and other entities that contract or subcontract with Part D Sponsors to administer the Medicare prescription drug benefit. This provision is designed to provide more timely access to records, including for investigations of Part D fraud and abuse, and responds to recommendations from the Department of Health and Human Services (HHS) Office of Inspector General.


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