Statement on Medicare Advantage and Part D Programs Contract Year 2025 Final Rule

By Soumi Saha, Senior Vice President, Government Affairs

Premier has long championed full and equitable access to medically necessary behavioral health services and is encouraged that the Centers for Medicare & Medicaid Services (CMS) finalized policies that will help close gaps in treatment access for mental health, substance use and co-occurring disorders for Medicare Advantage (MA) beneficiaries.

A glaring omission from this rule is vigilant monitoring and enforcement by CMS to verify that MA beneficiaries receive their entitled benefits. The need for this increased oversight emerged loud and clear from a recent survey conducted by Premier among hospitals, health systems and post-acute care providers that sought to gauge the extent of payment denials and delays by private payers. The survey found that more than 52 percent of claims initially rejected by MA plans were eventually overturned and paid after multiple provider appeals, resulting in significant care delays for patients and billions of dollars in waste to the US healthcare system. These alarming results led Premier, along with 118 healthcare entities including hospitals, health systems, post-acute care facilities, physician offices, and other providers to call for a series of reforms to curb these types of behaviors by MA plans and protect patients’ access to timely care. Premier will continue to call for these reforms as part of the MA Data Request for Information.

Finally, Premier commends CMS for granting flexibility to Part D sponsors in handling formulary substitutions of non-interchangeable biosimilars as "maintenance changes," eliminating the need for CMS approval. Biosimilars have been recognized for their potential to enhance patient access to medications and generate substantial savings for the US healthcare system. However, certain vertically-integrated payers have prioritized their profits over reducing drug costs for patients by favoring reference biologics and lucrative rebates, despite the known benefits of biosimilars. Premier has consistently advocated for CMS to enhance policy proposals that promote biosimilar adoption, ensure fair and unbiased payment policies, and prioritize patient welfare.