Medicare Final Rule

The Medicare Final Rule is a yearly publication by the Centers for Medicare & Medicaid Services (CMS) that sets out the policies and payment rates for Medicare services for the upcoming year. The Final Rule is released every fall and becomes effective on January 1st of the following year.

What does the Medicare final rule cover?

The Final Rule covers a wide range of topics, including changes to the Medicare Advantage and Prescription Drug Benefit programs, updates to quality reporting programs, and changes to reimbursement rates for healthcare providers. It is based on a proposed rule released earlier in the year, which is open for public comment. CMS considers feedback from stakeholders before issuing the final rule.

What is the final rule for 2023 Medicare?

We are pleased to share with you the latest information on the final 2023 Medicare Advantage and Part D prescription drug rules released by the Centers for Medicare & Medicaid Services (CMS). As healthcare industry leaders, we understand the importance of staying up-to-date on these changes to ensure optimal care for our patients.

Here are the top 10 things you need to know about the final rule:

Medicare Star Ratings

The final rule adds Star Ratings as a measure of Medicare Advantage (MA) and Part D organizations’ performance in managing prescription drug costs. This measure will incentivize organizations to lower drug costs and improve quality of care for patients.

Medicare Coverage Gap Discount

The coverage gap discount for brand-name drugs will increase from 75% to 85% in 2023. This will result in lower out-of-pocket costs for patients who fall into the coverage gap.

Medicare Beneficiary Access to E-Prescribing

CMS has mandated that all Medicare Part D plans provide electronic prescribing (e-prescribing) at the point-of-care by January 1, 2023. This will improve medication safety and reduce errors in prescribing.

Medicare Formulary Requirements

CMS has revised formulary requirements to allow for more flexibility in plan design, while also ensuring access to medically necessary drugs. This will allow MA and Part D organizations to tailor their plans to meet the specific needs of their patients.

Medicare Step Therapy

Step therapy, a process in which patients must try lower-cost drugs before more expensive options, will now be allowed for Part B drugs in certain circumstances. This will help control costs while still ensuring patients have access to necessary treatments.

Medicare Opioid Policies

CMS has updated its opioid overutilization policies to encourage appropriate prescribing and ensure safe use of these drugs. This includes establishing a seven-day supply limit for initial opioid prescriptions and implementing drug management programs for at-risk patients.

Medicare Telehealth Services

CMS has expanded access to telehealth services for MA plans, allowing patients to receive care remotely when appropriate. This will improve access to care for patients in rural or underserved areas, as well as those with mobility issues.

Medicare Value-Based Insurance Design (VBID)

CMS is expanding VBID in Medicare Advantage to allow for more flexibility in plan design, while also ensuring access to medically necessary drugs. This will help reduce costs while still providing high-quality care for patients.

Medicare Encounter Data

CMS is improving the accuracy and completeness of encounter data used for risk adjustment purposes. This will ensure that MA plans are reimbursed appropriately for the care they provide to their patients.

Medicare Quality Bonus Payment (QBP) Demonstration

CMS is launching a QBP demonstration to test alternative methods for calculating and distributing quality bonus payments. This will allow CMS to determine the most effective ways to incentivize high-quality care and improve patient outcomes.

The final 2023 Medicare Advantage and Part D prescription drug rules

In conclusion, the final 2023 Medicare Advantage and Part D prescription drug rules represent a significant step forward in improving healthcare for patients. These changes will incentivize organizations to provide high-quality care while controlling costs and improving access to care for patients. As healthcare leaders, it is our responsibility to stay informed and ensure that our patients receive the best possible care.

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Posted on May 2023