CMS has proposed a rule that would allow coverage for obesity medications under Medicare and Medicaid starting in 2026. This change aims to address the obesity epidemic in the United States.
The proposed rule by CMS reclassifies obesity drugs as treatments for chronic diseases. This would enable approximately 3.4 million individuals to gain access to obesity drug coverage through Medicare Part D. The projected cost to the federal government over the next decade is estimated to be $25 billion.
The financial implications of this proposed coverage are substantial. The federal government is expected to shoulder $11 billion of the costs over the next ten years, while states would be responsible for approximately $3.8 billion. This collaborative funding approach aims to alleviate the financial burden on states while expanding access to essential medications for millions of Americans.
CMS is also addressing concerns related to prior authorization processes within Medicare Advantage (MA) plans. Recent data indicates that MA plans overturn 80% of their denied claims upon appeal, yet less than 4% of denied claims are actually appealed. This discrepancy suggests that many beneficiaries may be unaware of their rights to challenge denials.
To enhance transparency regarding internal coverage criteria and appeal rights, CMS is proposing measures that empower enrollees. These changes aim to ensure that beneficiaries have access to clear information about their options when faced with denied claims.
CMS is advocating for the inclusion of comprehensive provider directories in the CMS Medicare Plan Finder. This would enable beneficiaries to make informed choices about their healthcare providers. The goal is to empower individuals by providing them with the necessary information to make educated decisions regarding their healthcare.
CMS is implementing guardrails to ensure that the use of artificial intelligence (AI) in healthcare does not hinder access to essential health services. These measures aim to strike a balance between leveraging AI technology for improved healthcare outcomes while ensuring equitable access to care for all beneficiaries.
CMS is taking steps to address competition within the Medicare Advantage and Part D programs. Proposed updates to the Medical Loss Ratio (MLR) regulations aim to improve the accuracy of data reported by plans.
In addition, CMS is expanding its oversight of Medicare Advantage advertisements due to identified instances of misleading marketing practices. These initiatives build on previous policies designed to protect Medicare beneficiaries from predatory marketing tactics.
These proposed changes by CMS reflect a commitment to enhancing access to care, improving transparency, and fostering a more equitable system for all beneficiaries. The aim is to create a healthcare system that provides better opportunities for individuals to receive the care they need and deserve.