You want a sign that Medicare Part D is now a mature business? The best evidence of this may be that Part D plans seemingly have become CMS’s prime regulatory focus. And the clearest indicator of that may be the 2013 Medicare Advantage and Part D call letter CMS issued last month. There are at least three significant new regulatory initiatives directed at Part D plans, and it looks as though they only will grow in future years.
Consider first the issue of preferred versus nonpreferred pharmacy networks that Part D plans increasingly have adopted. CMS has become convinced that beneficiaries are confused “over whether preferred cost sharing is available at individual pharmacies,” the agency said in the call letter. For now, it’s just changing the online Medicare Plan Finder to require beneficiaries using it to select a pharmacy for purposes of getting cost estimates that reflect the pharmacy’s status of preferred or nonpreferred, and intends to compel sponsors to designate their pharmacy contracts as preferred or nonpreferred. But if these steps don’t solve what CMS perceives — and some industry observers agree — to be a problem, look for more regulatory initiatives.
Then there is the 10-page section in the call letter on Part D medication therapy management (MTM) initiatives. CMS is looking for Part D plans to demonstrate that their MTM-eligible beneficiaries are getting required service levels for comprehensive medication reviews. And the agency said it is developing a MTM star-rating quality measure for display in 2013 and actual use in star scoring for 2014. Look for new CMS audits and perhaps “secret shopping” for MTM starting perhaps as early as this summer. Moreover, CMS indicated it may subject stand-alone Medicare Prescription Drug Plans (PDPs) to the same kind of out-of-pocket cost-sharing thresholds for increases in cost sharing and premiums that MA plans have had to meet the past two years.
There was a time — not too long ago since they didn’t start till 2006 — when Part D plans were the “new kid on the block,” and the big question was just whether they would they get enough customers. The answer overwhelmingly has been yes, so now comes a much heavier dose of regulation. Is this how it should be, and just a “welcome to the big leagues”? Or is there a danger that this much new regulation might stunt the six-year-old’s growth?