CMS Issues Pared-Down Final Rule on Medicare Part D and Medicare Advantage


CMS recently issued a Final Rule with respect to the Medicare Part D and Medicare Advantage programs (the “Final Rule”) implementing certain Affordable Care Act provisions.  The Final Rule follows a January 10, 2014 Notice of Proposed Rulemaking (the “Proposed Rule”) in which CMS proposed dozens of new or amended regulations.  In the Final Rule, however, CMS stated that many of the provisions of the Proposed Rule will either “be addressed later” or are “effectively being withdrawn.” For instance, the Final Rule contains a table indicating that at least 42 provisions of the Proposed Rule are not being addressed in the Final Rule.  (See Table 3 of the Final Rule.)

In the preamble, CMS summarized the four major provisions of the Final Rule.  First, CMS stated that the Final Rule modifies the agent/broker requirements for Medicare Advantage organizations.  Second, CMS explained that it is declining to finalize any new criteria for “drug criteria or classes of clinical concern.”  Third, CMS stated that the Final Rule adds two new regulatory provisions that “codify the Affordable Care Act requirement . . . that [Medicare Advantage] organizations and Part D sponsors report and return identified Medicare overpayments.”  Finally, CMS indicated that the Final Rule “strengthen[s] existing regulations related to the accuracy of risk adjustment data, including (1) a requirement that medical record reviews, if used, be designed to determine the accuracy of diagnoses . . . ; (2) a revision in the deadlines for submission of risk adjustment data; and (3) a limitation on the type and purpose of late data submissions.”

A copy of the Final Rule is available here, and a copy of the Proposed Rule is available here.

Reporter, Ramsey Prather, Atlanta, + 1 404 572 4624,


DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.

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