Stay Informed with Our Health Policy Insights

This week has seen significant developments in health policy, particularly concerning Medicare, Medicaid, and health equity. Here are three noteworthy stories:

1. Appointment of Dr. Mehmet Oz to Lead CMS

President-elect Donald Trump has nominated Dr. Mehmet Oz to head the Centers for Medicare and Medicaid Services (CMS). Dr. Mehmet Oz is a cardiothoracic surgeon, author, and television personality widely known for hosting "The Dr. Oz Show," a daytime television program that focuses on health, wellness, and medical advice. In 2022, Dr. Oz ran as a Republican candidate for the U.S. Senate in Pennsylvania. He positioned himself as a conservative voice on healthcare and social issues but lost to Democrat John Fetterman in the general election.

2. CMS Releases the 2026 Medicare Advantage and Part D Technical Rule

On November 26, 2024, CMS proposed a rule introducing significant changes to the Medicare Advantage (MA) and Prescription Drug (Part D) programs for contract year 2026. The proposal aims to enhance oversight and strengthen beneficiary protections within these programs.

Key Provisions of the Proposed Rule:

• Prior Authorization Reforms: The rule seeks to implement new guardrails on prior authorization processes within Medicare Advantage plans. These measures are designed to ensure timely access to medically necessary services for beneficiaries, addressing concerns about delays and denials of care.

• Marketing and Communications Oversight: CMS proposes stricter regulations on marketing practices to prevent misleading information and to protect beneficiaries from aggressive or deceptive marketing tactics. This includes enhanced scrutiny of third-party marketing organizations and clearer guidelines to ensure beneficiaries receive accurate information about their plan options.

• Health Equity Initiatives: The proposed rule emphasizes the advancement of health equity by encouraging Medicare Advantage and Part D plans to address social determinants of health and to reduce disparities in care among underserved populations. This aligns with CMS's broader commitment to promoting equitable healthcare access and outcomes.

3. CMS Releases Guidance on Medicaid Ex Parte Renewals

On November 26, 2024, CMS issued an informational bulletin titled "Basic Requirements for Conducting Ex Parte Renewals of Medicaid and CHIP Eligibility." This document outlines the mandatory procedures for states to renew Medicaid and Children's Health Insurance Program (CHIP) eligibility using available reliable information without requiring beneficiary contact, a process known as ex parte renewal.

Key Highlights:

• Ex Parte Renewal Process: States are required to utilize information already available within their systems or from other reliable data sources to determine ongoing eligibility for beneficiaries, minimizing the need for direct beneficiary involvement.

• Verification of Eligibility Criteria: The guidance emphasizes the importance of verifying both financial and non-financial eligibility criteria through existing data, ensuring that beneficiaries who remain eligible continue to receive benefits without unnecessary administrative hurdles.

• Enhancing Efficiency: By streamlining the renewal process through ex parte methods, states can reduce administrative burdens and improve the continuity of coverage for eligible individuals.

This guidance is part of CMS's ongoing efforts to support states in maintaining program integrity while facilitating access to healthcare for eligible populations. States are encouraged to review and implement these procedures to ensure compliance and to promote efficient and beneficiary-friendly renewal processes.