CMS Finalizes Changes to Medicare Advantage and Part D Programs

King & Spalding

On February 6, 2015, CMS released a final rule revising certain requirements for the Medicare Advantage and Part D programs. The changes will be effective for Contract Year 2016. According to CMS, the final rule implements statutory requirements, improves program efficiencies, strengthens beneficiary protections, clarifies program requirements, and improves payment accuracy.

Among the changes, the final rule revises certain requirements related to efficient dispensing of drugs to Part D enrollees in long-term care facilities. The final rule prohibits payment arrangements that penalize the offering and adoption of more efficient dispensing techniques by prorating dispensing fees based on days’ supply or quantity dispensed and also adds a requirement that any difference in payment methodology incentivize more efficient dispensing techniques.

Additionally, the final rule requires Medicare Advantage prescription drug plans to establish and maintain a process with network pharmacies to ensure timely and accurate point-of-sale transactions. The final rule also finalizes changes to audit and inspection authority. CMS may now require Medicare Advantage organizations and Part D plan sponsors to hire an independent auditor to validate corrections of CMS audit findings. CMS, however, is not finalizing its proposed language that would have required plan sponsors to hire an independent auditor to conduct full or partial program audits.

CMS also did not finalize several other major provisions from the proposed rule. Specifically, the final rule did not adopt:

  • the lifting of protected class designation on antidepressants, antipsychotics, and immunosuppressants for transplant rejection;
  • the proposed requirement that Medicare Part D sponsors include any pharmacy willing to accept the terms and conditions in narrower pharmacy networks that offer preferred cost sharing; and
  • the proposed reduction in the number of Part D plans a sponsor may offer.

To view the final rule, click here. To view CMS’s fact sheet, click here.

Reporter, Isabella Edmundson, Atlanta, + 1 404 572 3527,

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King & Spalding

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