Just before Thanksgiving, the Centers for Medicare and Medicaid Services (CMS) released its proposed Medicare Advantage (MA) and Medicare Part D (prescription drug) plan rules for calendar year (CY) 2027. Generally, the proposal revises CMS’ star rating system, modifies enrollment rules for individuals whose providers are leaving their current plan, and requests comments on MA program improvements.
The rule proposes new special enrollment period (SEP) rules for when a person’s medical care provider is terminated from their MA plan’s network. The proposal would allow impacted enrollees to change plans or to return to original Medicare and obtain a Medigap policy, on a guaranteed issue basis, outside the regular enrollment period when a provider leaves the network mid-year.
The proposed rule would modify CMS’s long-standing mid-year termination policy by removing the limitation that requires the network change to be deemed significant. The SEP rules require plans to notify affected enrollees in writing within a specified time frame (e.g., within 45 days for primary care physicians) about the termination. The plan would have to include in the notification information on other available providers and plan options.
The Notice also proposes changes to the star rating system used for MA plans and Medicare Part D (prescription drug) plans. CMS said the changes are designed to incentivize MA and Part D plans to improve care for enrollees. The rule would replace 12 unique measuring elements with “a more focused system that better serves the core purpose of measuring and incentivizing quality improvements that directly benefit people enrolled in MA and Part D, while reducing unnecessary administrative burden on plans. The changes retain many measures focused on clinical care, outcomes, and patient experience. CMS also proposes to introduce a new Depression Screening and Follow-Up measure that would begin with the 2029 Star Ratings to address critical mental health needs among beneficiaries. Together, these changes will rebalance CMS’s inventory of measures within the Star Ratings system to focus more on health outcomes and preventive care.”
The proposed rule also includes a request for information (RFI) on “how to modernize MA, options to improve competition, refine risk adjustment, and align quality incentives to deliver greater value for beneficiaries and taxpayers. The RFI seeks public input on ways CMS could achieve these efforts through either a time-limited model test under the CMS’ Innovation Center’s authority or potential program-wide regulatory changes.”
A fact sheet on the proposed rule is posted at https://www.cms.gov/newsroom/fact-sheets/contract-year-2027-medicare-advantage-part-d-proposed-rule.
Prospects: The proposed rule is open for public comment until February 9, 60 days after its publication in the Federal Register. NAIFA will submit comments.
NAIFA Staff Contact: Mike Hedge – Senior Director – Government Relations, at mhedge@naifa.org;.