The Biden-Harris Administration’s recent announcement on promoting competition in healthcare includes a significant focus on increasing transparency in the Medicare Advantage (MA) insurance market. The U.S. Department of Health and Human Services (HHS) and the Centers for Medicare & Medicaid Services (CMS) have taken proactive steps to enhance data capabilities and transparency in the MA program.

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Key Points Health Plans and PBMs Need to Know:

Rationale for Transparency:
The administration aims to address the lack of transparency in Medicare Advantage managed care plans, ensuring that Americans with Medicare have access to critical information for making informed decisions about their healthcare.

Request for Information (RFI):
CMS has released a Request for Information (RFI) to gather public feedback on enhancing MA data capabilities and increasing transparency. This move is crucial as MA enrollment has exceeded 50% of Medicare, with over $7 trillion expected to be paid to MA health insurance companies in the next decade.

Extended Comment Period:
The RFI comes with an extended comment period of 120 days to encourage input from a broad range of stakeholders. This extended period allows for comprehensive feedback and collaboration among various entities in the healthcare ecosystem.

Areas of Focus:
CMS is seeking input on various aspects of the MA program, including access to care, prior authorization, provider directories, networks, supplemental benefits, marketing, care quality, outcomes, value-based care arrangements, equity, and market competition.

Existing Data Transparency Efforts:
CMS has already taken steps to improve transparency in the MA market, such as collecting more comprehensive payment data related to Medical Loss Ratios, new data streams for supplemental benefits costs and utilization, and increased requirements for encounter data completeness.

Prior Authorization and Interoperability:
As announced earlier this year, CMS has finalized requirements for MA organizations to publicly report data on prior authorization denials and approvals, as well as proposed requirements for MA plans to publicly post annual health equity analysis of prior authorization policies and procedures.

Race and Ethnicity Data:
Efforts around race and ethnicity data have begun and include the voluntary collection of data on MA and Part D enrollment forms and the phased-in use of encounter data in calculating risk scores, emphasizing more complete and accurate reporting.

Next Steps:
The MA Data RFI is a pivotal step in the administration’s commitment to transparency. The solicited information will guide efforts to protect enrollees, drive high-quality care, and foster healthy competition in the MA market.

Health plans and PBMs operating in the Medicare Advantage landscape should closely follow these developments. The administration’s commitment to transparency and the solicitation of feedback through the RFI reflect a dedicated effort to enhance the MA program, ensuring it meets the evolving needs of enrollees while promoting fair competition in the healthcare market. Stay informed and engaged to contribute valuable insights during the extended comment period.

Agadia’s HITRUST certified, prior authorization solution, PAHub, seamlessly aligns with the CMS directives on prior authorization and interoperability. PAHub not only ensures compliance with CMS guidelines but also empowers health plans and PBMs to streamline and control clinical, compliance, and administrative aspects of prior authorization, contributing to improved efficiency, reduced turn-around times, and enhanced overall quality of care. Contact us today to schedule a demo.

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