The Centers for Medicare and Medicaid Services (CMS) finalized a Medicare Advantage (MA) rule proposed by the Biden administration, but is choosing to leave out the rule’s flashiest policy.
As outlined by CMS, the Trump administration’s final rule will not include three proposals included in the initial proposal, including the plan to cover anti-obesity medications.
The previous administration attempted to have Medicare Part D and Medicaid cover anti-obesity drugs under the Contract Year 2026 MA and Part D rule, which would have substantially increased access to GLP-1 drugs for weight loss (some other indications are currently permitted).
“This change would have been transformative for the millions of individuals living with obesity who rely on these programs to access needed care, and would have helped to lessen the impact of the over 200 other health complications associated with the disease,” said Alliance for Women’s Health and Prevention CEO Millicent Gorham in a statement.
Despite support from some groups for the forward-looking approach to rein in healthcare costs long-term and dramatically improve health outcomes, other stakeholders, like the Alliance for Community Health Plans, worried the policy would be a financial catastrophe to the healthcare system.
Department of Health and Human Services (HHS) Secretary Robert F. Kennedy Jr. has been vocally skeptical of the role GLP-1 drugs play on society, instead preferring non-prescription solutions to reverse chronic disease and rein in healthcare costs.
The rule (PDF) also does not include an annual health equity analysis of utilization management policies and procedures, or new guardrails on artificial intelligence in the MA program.
“CMS, however, does want to acknowledge the broad interest in regulation of AI and will continue to consider the extent to which it may be appropriate to engage in future rulemaking in this area,” the final rule said, making no mention of anti-obesity medications.
Protections aimed at improving oversight of marketing materials produced by agents and brokers were not included in the rule either. These requirements would’ve broadened the definition of marketing, after the agency received complaints certain types of advertisements could be deemed misleading.
For proposals not included in the rule, CMS said it reserves the right to include provisions in future rulemaking. Notably, the final rule said Medicare program regulations will continued to be monitored to abide by a Trump executive order requiring the elimination of 10 existing regulations for every new regulation. The agency is reviewing the health equity index reward in the star ratings program, requirements for MA plans to provide “culturally and linguistically appropriate services” and health risk assessments focused on social determinants of health. However, HRAs must now be integrated between Medicare and Medicaid, and there are new timeframes for special needs plans to conduct HRAs.
“As we continue to review the final rule, we are encouraged that the administration took a measured approach and declined to make major changes at this time,” said Mary Beth Donahue, president and CEO of Better Medicare Alliance, a group promoting MA, in a a statement. “With millions of Medicare Advantage beneficiaries still facing significant impacts from two years of MA cuts and other policy changes, this is the right decision to protect seniors and the MA program.”
The agency’s scaled back rule does finalize a provision restricting a plans’ ability to reopen or modify an inpatient hospital decision once information is obtained after an approval, unless there is fraud or an error found.
“The goal of this provision is to ensure that if a plan approves an inpatient admission, it will have to honor the prior authorization,” the department said in a fact sheet released Friday.
CMS is also attempting to help close loopholes affecting beneficiaries and providers by tightening the appeals process. Premier, Inc., a network with hospital and provider members, was pleased by these decisions.
“Premier applauds the CMS final rule for closing loopholes and games played by Medicare Advantage payers that, left unchecked, place Medicare beneficiaries in a continual nightmarish loop of prior authorization,” the organization said in a statement. “Premier is especially thrilled to see CMS crack down on plans’ ability to retroactively deny approved hospital stays—because once medically necessary care is given, it shouldn’t be up for debate.”
A host of provisions required under the Inflation Reduction Act were codified under the final rule. It includes a requirement that a Medicare Part D deductible does not apply to adult vaccines recommended by the Advisory Committee on Immunization Practices and covered under Part D. There is also no cost-sharing.
This proposal also applies to insulin cost sharing, though the cost-sharing amount for a one-month supply “must not exceed the covered insulin product applicable cost-sharing amount,” the fact sheet said. After 2025, the cost-sharing amount is capped at $35. These policies require codification by the end of this year.
Special Supplemental Benefits for the Chronically Ill (SSBCI) will have renewed guardrails, meaning MA plans cannot offer junk food, alcohol, tobacco or life insurance as benefits falling under this category.
Most star ratings changes were postponed to a later date, except for a change to a breast cancer screening measure for the 2029 star ratings starting in January 2027.
CMS is expected to release a final MA rate notice by April 7.
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