The U.S. Department of Health and Human Services (HHS), through the Centers for Medicare & Medicaid Services (CMS), is finalizing a rule to put people with Medicare first and put strong protections in place so that Medicare Advantage (MA) works for them. This final rule will strengthen Medicare Advantage and hold health insurance companies to higher standards for America’s seniors and people with disabilities by cracking down on misleading marketing schemes by Medicare Advantage plans, Part D plans and their downstream entities; removing barriers to care created by complex coverage criteria and utilization management; and expanding access to behavioral health care. The new rule will also promote health equity, and implement a key provision of the Inflation Reduction Act—President Biden’s new law to lower prescription drug costs—that will improve access to affordable prescription drug coverage for an estimated 300,000 low-income individuals.

The Biden-Harris Administration is committed to protecting and strengthening Medicare for the 65 million people with Medicare today and for future generations. In the past few months, the Department has taken a series of actions to ensure the Medicare Advantage program works for people with Medicare and that private insurance companies are held accountable for providing quality coverage and care:

• In February, CMS finalized a rule to start recovering improper payments made to Medicare Advantage plans through audits for the first time since 2007. Recovering these improper payments and returning this money to the Medicare Trust Funds will protect the fiscal sustainability of Medicare and allow the program to better serve seniors and people with disabilities, today and in the future.
• Last week, CMS finalized policies in the 2024 Medicare Advantage and Part D Rate Announcement to improve payment accuracy and ensure taxpayer dollars are appropriately safeguarded and well-spent.

Cracking Down on Misleading Marketing Schemes

The final rule includes changes to protect people exploring Medicare Advantage and Part D coverage from confusing and potentially misleading marketing practices. Ads will be prohibited if they do not mention a specific plan name, or if they use the Medicare name, CMS logo, and products or information issued by the Federal Government, including the Medicare card, in a misleading way. Further, the final rule strengthens accountability for plans to monitor agent and broker activity.

Removing Barriers to Care Created by Complex Prior Authorization and Utilization Management

CMS is also providing important protections regarding utilization management policies and coverage criteria that ensure that Medicare Advantage enrollees receive the same access to medically necessary care that they would receive in Traditional Medicare. The rule streamlines prior authorization requirements and reduces disruption for enrollees by requiring that a granted prior authorization approval remains valid for as long as medically necessary to avoid disruptions in care, requiring Medicare Advantage plans to annually review utilization management policies, and requiring denials of coverage based on medical necessity be reviewed by health care professionals with relevant expertise before a denial can be issued. These policies complement proposals in CMS’ Advancing Interoperability and Improving Prior Authorization Processes Proposed Rule (CMS-0057-P).

Expanding Access to Behavioral Health Care

CMS remains committed to emphasizing the critical role that access to behavioral health plays in whole person care. In line with CMS’ Behavioral Health Strategy and the Administration’s strategy to address the national mental health crisis, CMS is strengthening behavioral health network adequacy in Medicare Advantage by adding clinical psychologists and licensed clinical social workers to the list of evaluated specialties. CMS is also finalizing wait time standards for behavioral health and primary care services and more specific notice requirements from plans to patients when these providers are dropped from their networks. In addition, CMS is requiring most types of Medicare Advantage plans to include behavioral health services in care coordination programs, ensuring that behavioral health care is a core part of person-centered care planning.

Promoting More Equitable Care

Additionally, CMS is advancing health equity and driving quality in health coverage by establishing a health equity index in the Star Ratings program that will reward Medicare Advantage and Medicare Part D plans that provide excellent care for underserved populations. Plans will also be required to provide culturally competent care to an expanded list of populations and to improve equitable access to care for those with limited English proficiency, through newly expanded requirements for providing materials in alternate formats and languages. The final rule balances patient experience/complaints measures, access measures, and health outcomes measures in the Star Ratings program to more effectively focus both on patient-centric care and on improving clinical outcomes.

Implementing President Biden’s New Prescription Drug Law

The final rule also implements a key provision of the Inflation Reduction Act that improves access to affordable prescription drug coverage for approximately 300,000 low-income individuals. As outlined in President Biden’s new prescription drug law, CMS is expanding eligibility for the full low-income subsidy benefit (also known as “Extra Help”) to individuals with incomes up to 150% of the federal poverty level who meet eligibility criteria. Beginning January 1, 2024, this change will provide the full low-income subsidy to those who would currently qualify for the partial low-income subsidy. As a result of this change, eligible enrollees will have no deductible, no premiums (if enrolled in a “benchmark” plan), and fixed, lowered copayments for certain medications under Medicare Part D.

View a fact sheet on the final rule.

The final rule can be accessed from the Federal Register at: https://www.federalregister.gov/public-inspection/2023-07115/medicare-program-contract-year-2024-policy-and-technical-changes-to-the-medicare-advantage-program.

Medicare Advantage Value-Based Insurance Design Model Extension

Additionally, today CMS is also releasing more information about the extension of the Center for Medicare and Medicaid Innovation’s Medicare Advantage Value-Based Insurance Design (VBID) Model from 2025 through 2030. This extension will introduce changes intended to more fully address the health-related social needs of patients, advance health equity, and improve care coordination for patients with serious illness. View the fact sheet, and more information, on the model webpage.

The Pennsylvania Association of Community Health Centers (PACHC) is hosting several career events this spring. Click on the event name for more information and to register.

• Community Health Career Networking Evening in Hershey (April 26) – Physicians, nurses, nurse practitioners, dentists, LCSWs, therapists, and other providers are invited to attend.
• Northeast PA Community Health Career Fair in Scranton (April 27) – Medical assistants, dental assistants, community health workers, LPNs, RNs, and other frontline staff are invited to attend.
• Northeast PA Community Health Career Networking Evening in Scranton (April 27) – Physicians, nurses, nurse practitioners, dentists, LCSWs, therapists, and other providers are invited to attend.
• Central PA Community Health Career Fair in Harrisburg (May 2) – Medical assistants, dental assistants, community health workers, LPNs, RNs, and other frontline staff are invited to attend.

For more information, contact Judd Mellinger-Blouch at Judd@pachc.org.

The Pennsylvania Department of Health published the Pennsylvania State Health Improvement Plan (SHIP) that outlines goals, objectives, and strategies to improve the health of all Pennsylvanians over the next five years. This unveiling of the plan coincided with National Public Health Week, April 3 through April 9.

The 2023-2028 SHIP was developed in collaboration with the Healthy Pennsylvania Partnership (HPP), with support from Harrisburg University. The HPP is made up of nearly 300 health care professionals, associations, health systems, health and human services organizations, community collaborations, local public health agencies, government agencies, and others focused on improving health outcomes across the Commonwealth.

“The Department’s vision is to create a ‘Healthy Pennsylvania for All,’” said Dr. Debra Bogen, Acting Secretary of Health. “Achieving that vision will take all of us working with people and organizations across the Commonwealth to increase opportunities for people to access quality health care, impactful programs, and needed resources.”

Under the overarching goal of improving the health status and life expectancy of Pennsylvanians, and eliminating health inequities, there are nine goals in the 2023-2028 SHIP:

• Increase financial well-being, food security, and safe affordable housing;
• Increase community safety by reducing the number of violent incidences that occur due to racism, discrimination, or domestic disputes;
• Improve environmental health, focusing on environmental justice communities;
• Increase the population at a healthy weight through increasing availability and accessibility of physical activity and affordable nutritious food;
• Reduce the impact of tobacco and nicotine use;
• Increase access to medical and oral health care;
• Improve mental health and substance use outcomes through improved mental health services, trauma-informed trainings, and substance use interventions;
• Improve health outcomes through improved chronic diseases management; and
• Improve maternal and infant health outcomes by improving prenatal, perinatal, and postnatal care.

Pennsylvania Governor Shapiro’s 2023-2024 budget supports many of the SHIP’s goals by proposing investments in key areas like $2.3 million to expand maternal health programming and study ways to reduce maternal mortality and morbidity, $500 million over the next five years for mental health services for students, and $16 million to increase the minimum Supplemental Nutrition Assistance Program (SNAP) benefit by 50%, among other investments.

The SHIP acts as a road map for the HPP and others to improve health outcomes and eliminate health disparities by working across the continuum from the social determinants of health, preventative interventions, and accessing quality and culturally humble care.

More information on the SHIP can be found on the Department of Health’s website at State Health Improvement Plan (pa.gov) or follow us on Facebook and Twitter.

Philadelphia Inquirer, Jason Nark, April 5, 2023

Berwick, a town of about 10,000 in Columbia County, is without a hospital for the first time in more than a century.

The emergency room was dark, the doors locked for months now, and a young woman stood outside in the rain, clutching her stomach and sobbing. No one was coming out to help.

The frantic people who drove the ailing woman to the hospital stood, dumbfounded, in the mostly empty parking lot.

“This is insane,” the driver said. “I’m going to have to call 911.”

On Sept. 17, the Pennsylvania Department of Health shut down Berwick Hospital Center’s emergency room because of a lack of staffing, accelerating a closure its owners planned out earlier that summer. Signs on the doors still advise patients to head to hospitals in Hazleton, 20 miles to the south, or Bloomsburg, 14 miles west, for emergencies. The 90-bed facility is currently operating only as a 14-bed inpatient geriatric psychiatry facility — but not everyone in this town of 10,349 on the Susquehanna River in Columbia County, knows that.

On that dreary March morning, the ill woman was carried back to a car to wait for an ambulance. Bette Grey, a Berwick resident and private medical advocate who fought, unsuccessfully, to keep the hospital open, was there to talk to The Inquirer. First, she watched her fears unfold.

“Hey, stay awake. Open your eyes,” Grey yelled, to the woman in the car, clapping her hands.

Read more.