In response to the Centers for Medicare & Medicaid Services’ (CMS) 2025 Proposed Final Rule, the Sacramento Association of Health Underwriters (SAHU) is taking a proactive stance to represent the interests of its members and the broader health insurance community.

CMS has introduced a comprehensive proposed final rule, CMS-4205-P, set to bring about substantial changes to Medicare Advantage and Part D programs, effective from the 2025 contracting year starting September 30, 2024. Notably, the proposed rule addresses critical aspects of Medicare marketing and communications policies, particularly impacting agent and broker compensation outlined in Section 1851(j) of the Act.

Key elements of the proposed final rule encompass the elimination of administrative fees and overrides, restrictions on services provided to Medicare agents, impacts on different agency types, changes in marketing reimbursements and Health Risk Assessments (HRA) fees, modifications in commission structures, and operational adjustments for agents and agencies.

SAHU and its board members believe that CMS-4205-P may have certain drawbacks, particularly as this policy would essentially leave agents and brokers unable to directly recover administrative costs. These adjustments impacting FMO/Agency support, training, technology, and related aspects will influence beneficiary options by diminishing the number of agents not only promoting Medicare Advantage but also providing a diverse range of plans. In essence, this regulation is poised to yield outcomes contrary to its intended objectives.

“Field Marketing Organizations (FMOs) are General Agents who provide training, and a multitude of compliance expertise to field agents. Agents struggled to comply with the recent CMS recording requirements, but FMOs were able to quickly provide a scalable solution. Without the general support of FMOs, insurance carriers would need to provide these services, raising their administrative costs and premiums to beneficiaries.” Says, NABIP CEO Jessica Brooks-Woods.

With the CMS-4205-P proposal open for public comment until January 5th, SAHU urges its members and the broader community to unite in advocating for the best interests of our clients and the sustained strength of our profession. We encourage everyone to contribute professional and constructive feedback, and comments can be conveniently submitted through Regulations.gov.

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For over 30 years, SAHU has worked to improve our members’ ability to meet the health, financial and retirement security needs of all Californians and Americans through education, advocacy, and professional development. For more information, please visit: sahu-ca.com. 

Important industry news brought to you by Sacramento Association of Health Underwriters (SAHU).

The Centers for Medicare & Medicaid Services (CMS) revealed on Thursday, August 31^st 2023, that the initial group of ten Medicare Part D medications slated for negotiation under the Inflation Reduction Act (IRA) has been identified.

These drugs have been designated based on the outlined criteria within the IRA. This legislation mandates that CMS prioritize drugs with the highest Medicare expenditure and minimal competition, among other considerations. The resulting roster encompasses medications that are crucial for numerous Medicare recipients in treating various conditions such as cancer, diabetes, blood clotting, heart failure, autoimmune disorders, and chronic kidney disease.

Negotiations regarding pricing will commence this year between CMS and the participating pharmaceutical manufacturers. Finalized prices will be disclosed next autumn by CMS, with implementation set for 2026. In the ensuing years, additional medicines will be included for negotiation.

Projected Benefits for Beneficiaries and Medicare

In 2022, the U.S. Department of Health and Human Services (HHS) approximated that the expenses for the chosen ten drugs totaled $3.4 billion in out-of-pocket payments for Medicare beneficiaries. While the specific savings for individual beneficiaries through the IRA’s negotiation initiative will be contingent on the forthcoming reductions in prices, overall reduced costs are anticipated across the board. It is noteworthy that the Congressional Budget Office (CBO) predicts that these negotiations could save Medicare a total of $98.5 billion over a ten-year span, subsequently leading to decreased financial burdens for beneficiaries and taxpayers. Importantly, this law will achieve these outcomes while simultaneously enhancing health results and program stability. The CBO underscores that the lowered drug costs will encourage better adherence to prescribed medications, ultimately enhancing beneficiary well-being and diminishing the necessity for more expensive medical care covered by Medicare.

Furthermore, complementary reforms tied to the IRA are either already in effect or will soon be implemented, further enhancing the affordability and accessibility for beneficiaries. Several key measures are already active, such as capping monthly insulin prescription costs at $35, providing no-cost Part D vaccines, and reducing coinsurance for certain Part B drugs. In the upcoming year, an increased number of Medicare beneficiaries will experience relief as the IRA abolishes enrollee expenditures in the Part D catastrophic phase and extends full Part D Low Income Subsidy (LIS) coverage to individuals with incomes equal to or less than 150% of the poverty threshold. By 2025, the legislation will also impose a limit of $2,000 per year on beneficiary Part D drug expenses and allow beneficiaries to pay these costs in more predictable monthly installments, offering vital financial security.

Previous estimates from HHS indicated that the Part D changes brought about by the IRA would save a minimum of $400 for one out of every three enrollees in 2025. Notably, a considerable number of beneficiaries will experience even more substantial savings: over eight million will witness a $759 reduction, and nearly two million will benefit from a $2,500 decrease, reflecting a 66% reduction relative to their present costs. Once the negotiation program is initiated in 2026, these savings are expected to expand further.

Engaging the Public

This initiative encompasses ten virtual public Listening Sessions set to take place in the upcoming fall, with each session focusing on one of the selected drugs. The agency has stated that this series will “offer an avenue for patients, beneficiaries, caregivers, consumer and patient organizations, and other interested parties to provide input relevant to the drugs chosen for the initial round of negotiations.” Stakeholders are required to pre-register for the opportunity to make live, public statements.

“It’s important for insurance agents to educate their clients about the impact of the Inflation Reduction Act this year more than ever.” Rosamaria Marrujo, past SAHU president and incoming CAHIP president.

Additionally, CMS will accept written statements from September 1 to October 2, 2023. Further details about how to contribute to CMS concerning the negotiation process can be found here
https://www.cms.gov/inflation-reduction-act-and-medicare/medicare-drug-price-negotiation

For More Information:
To access the CMS announcement, click here.

For a comprehensive fact sheet from CMS about the drugs selected for the Medicare Drug Price Negotiation Program, along with additional details about patient-focused listening sessions, please visit this link.
https://www.cms.gov/files/document/fact-sheet-medicare-selected-drug-negotiation-list-ipay-2026.pdf

For further information about the upcoming listening sessions and the opportunity for written comments, refer to this resource.
https://www.cms.gov/inflation-reduction-act-and-medicare/medicare-drug-price-negotiation-program-patient-focused-listening-sessions

For in-depth insights into the Medicare Drug Price Negotiation Program, explore further here.
https://www.cms.gov/inflation-reduction-act-and-medicare/medicare-drug-price-negotiation

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For over 30 years, SAHU has worked to improve our members’ ability to meet the health, financial and retirement security needs of all Californians and Americans through education, advocacy, and professional development. For more information, please visit: sahu-ca.com.