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Proposed Rule Would Expand Access to Anti-Obesity Medications and Builds on Previous Policies to Improve Enrollee Protections





Centers for Medicare & Medicaid ServicesNewsroom




FOR IMMEDIATE RELEASE
November 26, 2024

Contact: CMS Media Relations
CMS Media Inquiries [ https://www.cms.gov/About-CMS/Public-Affairs/PressContacts/Media-inquiries1.html ]

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*Biden-Harris Administration Announces Medicare Advantage and Medicare Part D Prescription Drug Proposals that Aim to Improve Care and Access for Enrollees*

"Proposed Rule Would Expand Access to Anti-Obesity Medications and Builds on Previous Policies to Improve Enrollee Protections and Competition"

* *Today, the Centers for Medicare & Medicaid Services (CMS) is proposing actions in the Medicare Advantage (MA) and Medicare Part D prescription drug programs to continue to strengthen protections and access to care for people with Medicare. The Contract Year (CY) 2026 MA and Part D proposed rule aims to hold MA and Part D plans more accountable for delivering high-quality coverage so that people with Medicare are connected to the care they need when they need it. In recognition of the prevailing medical consensus that obesity is a disease, CMS is proposing to reinterpret the statute to no longer exclude anti-obesity medications for the treatment of obesity from coverage under Medicare Part D and to require Medicaid programs to cover these medications when used to treat obesity. This proposal would provide more Americans access to these transformative medications, improving the health and quality of life for millions of people who have obesity.

This proposed rule continues the Biden-Harris Administration’s work to ensure the MA and Part D programs meet the needs of people with Medicare. In recent years, there have been increasing calls for reforms related to MA prior authorization, utilization management, and coverage decisions. CMS remains concerned about barriers to accessing care and high burden on the system. For example, data reported to CMS by MA plans indicate that, on average, MA plans overturn 80% of their decisions to deny claims when those claims are appealed to the plan. These data also show that less than 4% of denied claims are appealed in the first place, meaning many more denials could potentially be overturned by the plan if they were appealed. Ultimately, what these and other data show is that MA enrollees may not be getting access to the care they need.  The proposed rule builds on CMS’ work to remove unnecessary barriers to care resulting from the inappropriate use of prior authorization and internal coverage criteria. The rule would also increase guardrails on the use of artificial intelligence (AI) to protect access to health services. Other proposed policies will promote competition on the things that matter to people enrolled in MA and Part D plans, further addressing misleading marketing practices, and enhancing consumer tools on Medicare.gov.

“Our loved ones with Medicare deserve care that puts their interests first. HHS is proposing to improve transparency, accountability, and consumer protections in Medicare Advantage and Part D plans so that everyone receives high-quality care,” said HHS Secretary Xavier Becerra. “To achieve that, we want to remove barriers that delay care or deny people services and medications they need to be healthy. In addition, we continue to promote competition for pharmacies and other health care businesses.”

“The Biden-Harris Administration has worked to ensure that the Medicare Advantage and Part D prescription drug programs work for people with Medicare, adopted policies holding plans accountable for providing high-quality health care, and protected the sustainability of the Medicare program,” said CMS Administrator Chiquita Brooks-LaSure. “This proposed rule continues to build on this work by expanding access to anti-obesity medications for people with Medicare and Medicaid, further addressing prior authorization concerns in Medicare Advantage, and promoting informed choice and transparency by requiring Medicare Advantage plans to share provider directory information on Medicare Plan Finder.” 

Over the past few years, CMS has made improvements to Medicare Plan Finder [ https://www.medicare.gov/plan-compare/#/?year=2024&lang=en ] based on research and feedback from the public. CMS has enhanced Medicare Plan Finder’s capabilities as an online tool that helps people with Medicare to compare Medicare options, including shopping for MA and Part D plans and comparing to Traditional Medicare. In this proposed rule, CMS is further proposing to enhance Medicare Plan Finder’s ability to provide a personalized experience for people with Medicare and their caregivers by proposing that MA organizations make their entire provider directory available to CMS, for the purpose of incorporating it into Medicare Plan Finder. This would enable people with Medicare and their caregivers to search for providers and more easily compare their availability across different MA plans.

“We continue to hear from people enrolled in Medicare Advantage who are having difficulty accessing the care they need and are entitled to, and CMS remains focused on removing these barriers,” said Meena Seshamani, MD, PhD, CMS Deputy Administrator and Director of the Center for Medicare. “Whether it’s difficulty navigating options, being able to afford the lifesaving medications you are prescribed by your doctor, or receiving the inpatient or rehabilitation care you need to get well, no senior or person with disabilities on Medicare should be having these challenges.” 

CMS is also addressing competition in the MA and Part D programs in this proposed rule. In line with the Biden-Harris Administration’s focus on promoting competition for consumers in health care, CMS is proposing to update the MA and Part D Medical Loss Ratio (MLR) regulations to improve the data reported by plans. CMS is seeking comment on policies regarding how the MA and Part D MLRs are calculated to help enable policymakers to address concerns surrounding vertical integration in MA organizations and Part D sponsors. In addition, CMS is taking steps to promote transparency for pharmacies.

Additionally, CMS is strengthening consumer protections by proposing changes to expand CMS oversight of MA advertisements, which would build on previously finalized policies to protect people with Medicare from predatory behavior, such as misleading television, web-based, and direct mail advertisements. Since 2023, CMS has issued denials for over 1,500 TV ad submissions that were non-compliant and misleading to consumers. CMS is also improving the proper administration of MA supplemental benefits through debit cards, better ensuring that CMS is a good steward of MA rebate dollars used for supplemental benefits and premium buy-downs, which, according to the Medicare Trustees, are estimated to amount to over $79 billion in 2026 and amount to approximately $500 billion over a 5-year period starting in 2026.

To review or comment on the CY 2026 MA and Part D proposed rule during its 60-day public comment period, visit the Federal Register [ https://www.federalregister.gov/public-inspection/2024-27939/medicare-and-medicaid-programs-contract-year-2026-policy-and-technical-changes-to-the-medicare ]. Comments must be submitted no later than January 27, 2025.

For more information on the CY 2026 MA and Part D proposed rule, view the fact sheet [ https://www.cms.gov/newsroom/fact-sheets/contract-year-2026-policy-and-technical-changes-medicare-advantage-program-medicare-prescription ].

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