sharp pencil with jumbled letters behind it - Tips and tools for social workers

Medicare Advantage, Medicare Prescription Drug Coverage, & PACE

Summary of NASW’s Comments on a Proposed Rule for 2024

By Chris Herman, MSW, LICSW Senior Practice Associate–Aging

In December 2022, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule (CMS–4201–P) addressing a few parts of the Medicare program: Part C, or Medicare Advantage (MA); the Part D prescription drug benefit; and the Program of All-inclusive Care for the Elderly (PACE). The proposed regulations, if finalized, will be implemented on January 1, 2024.

NASW submitted comments on the proposed rule in February 2023. The association’s comments addressed numerous topics, a few of which are summarized briefly in this Tips & Tools.

Health Equity and Related Access Provisions

Each MA plan must meet certain requirements that foster beneficiary access to services. These requirements include accommodating specific beneficiary populations to facilitate service access. NASW supported CMS’s proposal to expand the list of populations that may require consideration specific to their needs to include the following groups:

(i) people with limited English proficiency or reading skills; (ii) people of ethnic, cultural, racial, or religious minorities; (iii) people with disabilities; (iv) people who identify as lesbian, gay, bisexual, or other diverse sexual orientations; (v) people who identify as transgender, nonbinary, and other diverse gender identities, or people who were born intersex; (vi) people who live in rural areas and other areas with high levels of deprivation; and (vii) people otherwise adversely affected by persistent poverty or inequality. (CMS, 2022, p. 79480)

The association also offered comments on beneficiaries’ access to telehealth benefits within MA and to current MA plan provider directories. Moreover, NASW supported CMS’s proposals to improve standards for interpretation and teletypewriter services offered by MA and Part D plan call centers.

Medicare Advantage (MA) Network Adequacy

Each MA plan must meet certain network adequacy requirements—that is, it must contract with a certain number of providers across multiple specialties to serve Medicare beneficiaries in a specific area. The Trump Administration had weakened MA network adequacy requirements, thereby reducing beneficiary access to services. NASW recommended that CMS rescind changes made by the prior administration.

Behavioral Health in MA

Clinical social workers are not currently among the providers with which MA plans must contract. NASW strongly supported CMS’s proposal to add licensed clinical social workers, clinical psychologists, and prescribers of medication for opioid use disorder (MOUD) to the provider specialty types each MA plan must include in its network. The association also supported the following CMS proposals:

  • requiring MA plans to include “behavioral health services” in each plan
  • clarifying that some behavioral health services may qualify as emergency service sand, therefore, must not be subject to prior authorization
  • extending current requirements for MA plan sponsors to establish programs to coordinate covered services with community and social services to behavioral health services programs, thereby promoting parity in treatment between physical health and behavioral health
  • standardizing wait times for behavioral health services

Utilization Management in MA

As reports by the Government Accountability Office and the Office of the Inspector General (among others) have revealed, MA plans have a long-standing pattern of using prior authorization to limit beneficiary access to services. This means that MA enrollees may not have access to the same services that beneficiaries enrolled in original Medicare may have, despite federal requirements that forbid such disparities. In the proposed rule, CMS proposed unprecedented steps to curb inappropriate use of utilization management by MA plans. NASW applauded CMS for these proposals and recommended additional requirements to mitigate overuse of prior authorization by MA plans.

MA and Part D Marketing

Confusing—and, sometimes, misleading—marketing by MA plan sponsors (and, to some extent, by Part D plan sponsors) is another deeply entrenched problem, one that decreases the ability of beneficiaries to make informed decisions about Medicare coverage options. NASW supported multiple CMS proposals to strengthen marketing requirements for MA and Part D plan sponsors and recommended additional requirements to correct unclear and misleading plan marketing.

Access to Specialists in PACE

CMS proposed to require PACE plans to contract with multiple health care specialists, including psychiatrists, and requested comment regarding whether other behavioral health providers, such as psychologists and licensed clinical social workers, should be added to the list of required health care specialists with whom PACE organizations contract. NASW supported CMS’s first proposal and underscored that the ongoing psychosocial assessment, psychotherapy, and crisis intervention services provided by psychologists and licensed clinical social workers are essential complements to the prescribing and management services offered by psychiatrists.

Read NASW’s full comments to CMS for additional details regarding these and other topics addressed in the proposed rule.