Last fall, CMS proposed its usual, elaborate Part C/Part D rulemaking in November. The final has just come out (April 4,2025). A problematic section about Medicare Advantage was dropped.
See 90 FR 15792, April 15, 2025 (130pp). The proposal was 240pp, but many sections were dropped from further comment. The proposal's Table 1 had 17 topics. The final's Table 1 has 8 topics. The proposal use "equity" about 50 times; the final about 8, mostly to refer to the topic being dropped.
- The highest-publicity part was a proposal to cover Wegovy-type obesity drugs under Part D.
- Adminstration has dropped this propoal, period.
- It was always a little squirrely, since statute for Part D blocks coverage of weight loss drugs, so you had to argue the new-generation drugs were for "treating obesity" not "weight loss."
- The Problematic LCD Language
- Medicare Advantage plans are required to cover all regular Part B services (LCD or NCD), but barriers may intervene.
- CMS has done several rounds of recent policy-making to reduce tardy or absent compliance.
- In November 2024, CMS proposed that Medicare Advantage plans need only follow the clear language of LCDs, and SHALL NOT USE billing articles or other resources.
- This was a hang-up, because many LCDs state general coverage themes, but it's impossible to know which services (eg codes) are covered or not covered without the billing article.
- This is even a bigger deal with MolDx, which may explicitly guide readers to its DEX database for specific coverage (NOT billing articles, NOT the original LCD.)
- My nerdy blog on this.
- CMS simply eliminated this chapter, including public comment, from its final rule.
CMS also dropped several parts of the November proposal that referred to equity, social determinants of health, or language access. CMS dropped a section about "guardails" about using AI in denials or prior auth. The proposed rule had 17 topics (proposed, Table 1); the final maybe will have half or less topics.
Generally, when CMS disagreed with a proposal, it dropped it from the final rule rather than debate it.
The early, or typescript, version of the rule was released April 4, the final Federal Register version will appear April 15.
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Some long sections of the November 2024 proposed rule were simply dropped from the April 4 final rule. However, CMS has the option to return to them within 3 years of the original publication (see SSA 1873(a)(3)(B).) If CMS does not finalize the November 2024 proposals by November 2027 they are considered withdrawn by default under SSA 1873.
Some long sections of the November 2024 proposed rule were simply dropped from the April 4 final rule. However, CMS has the option to return to them within 3 years of the original publication (see SSA 1873(a)(3)(B).) If CMS does not finalize the November 2024 proposals by November 2027 they are considered withdrawn by default under SSA 1873.
