Medicare Part D/Medicare Advantage Rules
On January 12, 2009, CMS published a final rule that revises Medicare’s definition of Part D negotiated prices to require drug plan sponsors to use the amount paid to a pharmacy (rather than the sometimes lower "lock in price" paid to a pharmacy benefit manager) as the basis for determining cost sharing for beneficiaries and for reporting a plan’s drug costs to CMS. The rule also, among other things: requires new enrollees in special needs plans to be members of the population that the plan is designed to serve; permits CMS to impose on plans a civil money penalty of up to $25,000 for each enrollee adversely affected by a contract violation; codifies CMS policy regarding using the best available evidence to determine an enrollee’s eligibility for extra help through the Part D Low Income Subsidy program; prevents beneficiaries enrolled in Medicare Advantage and Part D plans who elect to have their premiums withheld from their Social Security payments from being double-billed for premiums; and requires Medicare Medical Savings Account plans to report cost and quality information to beneficiaries. CMS also issued a related proposed rule providing CMS with the authority to "waive or modify" statutory requirements pertaining to the Retiree Drug Subsidy (RDS) program in order to facilitate the offering of a prescription drug plan covering employees or retirees has also been released. Comments on the proposed rule will be accepted until March 13, 2009.
