CMS: Medicare Part D will not cover GLP-1s for weight loss

Changes to Medicare Advantage (MA), Medicare Part D

The announcement finalized several technical changes to both Medicare Advantage and Medicare Part D. For example, the agency finalized a provision that would limit an MA plan's ability to reopen and modify an already approved inpatient hospital decision "on the basis of information gathered after the approval."

"The goal of this provision is to ensure that if a plan approves an inpatient admission, it will have to honor the prior authorization," CMS said in a statement.

The agency also said it would close three MA appeals loopholes, including the following:

• Clarifying the definition of "organization determination." Decisions that are subject to MA appeal and notification requirements include certain MA plan decisions made at the same time as the enrollee's receipt of services.
• Codifying regulations requiring a provider notice of a coverage decision for those submitting requests on behalf of an enrollee. This provider notice should be in addition to an enrollee notice of a coverage decision.
• Clarifying that a member's financial responsibility cannot be determined until an MA plan determines the contracted provider's payment claim. This should let enrollees appeal MA plan coverage denials.

Next, the agency specified a list of non-allowable Special Supplemental Benefits for the Chronically Ill (SSBCI). SSBCI benefits address certain needs that are not directly related to health but that can impact health. For example, SSBCI benefits might address food insecurity or non-medical transportation.

CMS codified a list of non-allowable SSBCI, including items like "non-healthy food," alcohol, tobacco and life insurance.

Additionally, CMS issued technical updates for risk adjustment data, such as requiring PACE organizations and cost plans to submit risk adjustment data to the agency. Additionally, it changed language in the Hierarchical Condition Categories to refer simply to the International Classification of Diseases (ICD) rather than the specific iteration of ICD, such as ICD-9 or ICD-10.

Finally, CMS outlined new federal requirements for certain dual-eligible special needs plans (D-SNPs). By 2027, D-SNPs must have integrated member ID cards and conduct an integrated health risk assessment.

Addressing aspects of the Inflation Reduction Act

CMS noted that numerous provisions of the Inflation Reduction Act (IRA) of 2022 are set to expire at the end of 2025. In anticipation of that date, CMS finalized the following items:

• Vaccine cost sharing.
• Insulin cost sharing.

The agency also finalized parts of the Medicare Prescription Payment Plan with some modifications. CMS said it will finalize aspects of the plan that require an opt-out renewal process for Medicare Part D with some adjustments to the timing requirements for the process.

However, the agency said it will not finalize a proposal that requires Part D sponsors to ensure pharmacies can inform enrollees of their out-of-pocket costs for a Part D medication at the point of sale. CMS said this came in response to public comments on the proposal. Moreover, CMS said it will not finalize any changes to the 24-hour requirement for election effectuation.

Next, CMS finalized Prescription Drug Event (PDE) record submission requirements that are similar to those set out in the October 2011 guidance.

Finally, CMS finalized a proposal calling for Part D sponsors' network participation agreements to require that contracting pharmacies be enrolled in the Medicare Drug Price Negotiation Program's Medicare Transaction Facilitator Data Module. CMS said this will improve beneficiary access to selected drugs.

Sara Heath has covered news related to patient engagement and health equity since 2015.