NHC Comments on Medicare Prescription Payment Plan


NHC Comments on Medicare Prescription Payment Plan (PDF)

March 15, 2024

Chiquita Brooks-LaSure
Centers for Medicare & Medicaid Services
Department of Health and Human Services
7500 Security Boulevard
Baltimore, MD 21244

RE: Medicare Prescription Payment Plan: Draft Part Two Guidance on Select Topics, Implementation of Section 1860D-2 of the Social Security Act for 2025, and Solicitation of Comments

Submitted electronically to [email protected]

Dear Administrator Brooks-LaSure:

The National Health Council (NHC) appreciates the opportunity to provide comments to the Centers for Medicare & Medicaid Services (CMS) in response to the Medicare Prescription Payment Plan: Draft Part Two Guidance on Select Topics, Implementation of Section 1860D-2 of the Social Security Act for 2025, and Solicitation of Comments (draft Part Two guidance).

Created by and for patient organizations more than 100 years ago, the NHC brings diverse organizations together to forge consensus and drive patient-centered health policy. We promote increased access to affordable, high-value, equitable, and sustainable health care. Made up of 170 national health-related organizations and businesses, the NHC’s core membership includes the nation’s leading patient organizations. Other members include health-related associations and nonprofit organizations including the provider, research, and family caregiver communities; and businesses and organizations representing biopharmaceuticals, devices, diagnostics, generics, and payers.

As a vocal supporter of the MPPP and its potential benefits to people with chronic diseases and disabilities, the NHC appreciates CMS’ guidance on Part D sponsor duties in the draft Part Two guidance. While implementing this new program, it will be critical that CMS work with patients, patient advocacy groups, and other stakeholders to support choice and access to clear, understandable, and actionable information. This collaboration is particularly significant for people with chronic diseases and disabilities who are most likely to benefit from this new program. The NHC supports the development and use of processes and tools that enhance beneficiary experience, making interactions with the MPPP smoother and more intuitive for all beneficiaries. It is vital that communication, both for beneficiaries and for health care providers and pharmacists, adhere to these principles. The considerable discretion granted to Part D sponsors in operationalizing the program, while offering flexibility, also raises concerns about potential inconsistencies and unintended consequences that could impact beneficiary participation. To mitigate this, the NHC recommends that CMS refine its monitoring and oversight mechanisms, ensuring that all communication regarding the MPPP is inclusive, accessible, and accommodating of diverse needs, including but not limited to those with sensory or other disabilities and those with limited English proficiency (LEP). This includes standardization of materials and the use of CMS- provided language as well as examples of payment calculations to prevent confusion and variations in information provided by different plans and pharmacies.

Additionally, recognizing the complexity of health care information, the NHC underscores the need for CMS to partner with trusted messengers, such as patient organizations to co-create and/or review communication materials for usability and understandability, ensuring they are meaningful and actionable for all Medicare beneficiaries. Robust education, outreach efforts, and continuous monitoring and feedback mechanisms will be instrumental in ensuring the successful launch of this new program.

The NHC provides the following technical comments on the MPPP Part Two guidance.

30.  Outreach, Education, and Communications Requirements for Part D Sponsors

The NHC appreciates CMS’ guidance detailing Part D sponsors’ responsibilities in informing Medicare beneficiaries about the MPPP both prior to and during the plan year but is concerned over the emphasis on primarily targeting those likely to benefit from the program. This focus might overshadow the broader necessity of ensuring all beneficiaries receive comprehensive information about the program, potentially limiting informed decision-making opportunities for the wider Medicare population. The NHC underscores the importance of balancing focused outreach with widespread educational efforts to fully support beneficiary engagement and understanding across the entire spectrum of Medicare enrollees.

The NHC appreciates the mechanisms set forth for Part D sponsors to notify pharmacies — and, in turn, for pharmacies to inform beneficiaries — when a beneficiary’s out-of-pocket (OOP) costs for covered Part D drugs suggest potential benefits from participating in the MPPP. A similar mechanism would be helpful for health care providers to offer additional guidance and support to patients about the program. This collaborative approach between pharmacies and health care providers can create a comprehensive support system to ensure beneficiaries are well-informed to make decisions regarding their health care.

However, the NHC believes that the guidance would be further strengthened by explicitly emphasizing the involvement of patients and patient advocacy groups in the development, review, and refinement of educational materials. This collaborative effort will ensure that the materials are not only informative but also resonate with beneficiaries’ experiences and needs, thereby enhancing the effectiveness of the communications and ensuring that they are truly patient-centered.

Moreover, the NHC recommends that CMS consider introducing additional tools and resources, such as decision aids or interactive online platforms such as a monthly cost calculator, to aid beneficiaries in understanding the potential impacts of the MPPP on their personal prescription drug costs. These tools can empower beneficiaries with the information necessary to make more informed choices regarding their enrollment in the MPPP.

Lastly, the NHC stresses the importance of continuous monitoring and evaluation of the outreach, education, and communication strategies to identify areas for improvement.

This ongoing assessment will ensure that the information needs of all beneficiaries, especially those facing language and accessibility barriers, are adequately met. The NHC is eager to continue its collaborative efforts with CMS to enhance the MPPP’s outreach and education initiatives, ensuring its successful implementation for the benefit of all Medicare beneficiaries.

  • General Outreach and Education

While the NHC appreciates CMS’ outlined approach to outreach and education in the draft Part Two guidance, additional clarity regarding CMS’ strategies for widespread information dissemination to ensure that all Medicare beneficiaries, not just those immediately identified as likely to benefit, is needed. The NHC recommends that CMS collaborate with patient advocacy groups and beneficiaries to develop communications materials to ensure a patient-centered approach and that materials resonate with the diverse needs of the Medicare population. Additionally, the NHC recommends that CMS provide guidelines to ensure online content on plan websites is user-friendly and accessible to all beneficiaries, including those with disabilities or LEP. Furthermore, the NHC emphasizes the importance of deploying an accessible and reliable monthly cost calculator as described in the draft Part One guidance.1 This tool will be essential for providing beneficiaries with a clear understanding of their potential monthly expenses under the program and should be prioritized by CMS to ensure that beneficiaries have the necessary information to make informed decisions regarding their participation.2

The NHC supports the requirement to include MPPP details and an election request form with membership ID card mailings to new enrollees, ensuring immediate and clear communication upon plan entry. We recommend that CMS and Part D sponsors ensure these materials are concise, easily understandable, and tailored to meet the unique needs of all enrollees, including those with visual or cognitive impairments, leveraging CMS-developed educational products for uniformity while adapting them to specific enrollee needs.

Additionally, incorporating beneficiary feedback and pilot testing of revised Evidence of Coverage documents can ensure that MPPP information clarifies rather than complicates coverage understanding. For the Annual Notice of Change, accessible language that accommodates varied health literacy levels is vital. We recommend that CMS offers Part D sponsors best practices for clearly explaining the MPPP. Similarly, updating the Explanation of Benefits to include visual aids and examples will clarify MPPP’s impact on cost-sharing and coverage.

  • Targeted Outreach and Education Requirements for Part D Sponsors

The NHC supports the targeted outreach and education requirements outlined in the draft Part Two guidance but recommends a more inclusive and adaptive approach to communication strategies. The reach and effectiveness of CMS’ and Part D sponsors’ outreach efforts can be enhanced by integrating patient feedback and employing various communication channels, ensuring that all eligible Part D enrollees are well- informed to make decisions about their MPPP participation. Establishing a foundational knowledge level for all Part D beneficiaries is essential for ensuring those most likely to benefit from the program receive the necessary information to take action.

The NHC appreciates CMS’ standardized approach to the “Likely to Benefit Notice,” ensuring consistent information across Part D sponsors. However, to improve understanding of the MPPP’s impact on prescription drug costs and health care decisions, the NHC suggests augmenting this notice with additional educational resources, such as FAQs or interactive online tools. We acknowledge CMS’ efforts in requiring Part D sponsors to submit detailed MPPP participation data through established systems. However, to further empower beneficiaries and stakeholders, the NHC recommends CMS publicly report aggregated data on MPPP enrollees, including those terminated from the program and denied reentry in subsequent years. This data should be analyzed to identify trends and areas for improvement, facilitating ongoing program refinement and stakeholder engagement. Such transparency would not only uphold accountability but also enable stakeholders to contribute to the program’s continuous improvement, ensuring it better serves the evolving needs of Medicare beneficiaries.

The NHC appreciates the inclusion of a standardized framework by CMS to determine which enrollees are “likely to benefit” from the MPPP before and during the plan year by utilizing Prescription Drug Event (PDE) records to predict enrollees’ OOP expenses.

The NHC supports the minimum requirement for Part D sponsors to undertake targeted outreach to enrollees who are anticipated to incur high OOP costs for new prescriptions, potentially making them eligible for the MPPP, which will inform enrollees about the program before they face financial hardship at the pharmacy point-of-sale (POS).

Additionally, while CMS mandates that any additional identification criteria applied by Part D sponsors must be uniformly applied to all enrollees, the NHC encourages CMS to provide more explicit guidance on what these supplemental strategies might entail and how they can be implemented in a manner that ensures fairness and transparency.

The NHC expresses strong concerns regarding CMS’ revised criteria for notifying pharmacies about Part D enrollees’ eligibility for the MPPP based solely on single prescription thresholds. The shift to a single prescription threshold for alerting beneficiaries about potential MPPP benefits represents a significant departure from the draft Part One guidance, which considered cumulative OOP costs. This change could significantly narrow the pool of beneficiaries who are informed about the MPPP, potentially excluding individuals who cumulatively meet the eligibility threshold through multiple, less expensive medications. Many Medicare beneficiaries depend on a fixed income, primarily from Social Security, and meticulously budget for their health care costs on a monthly basis rather than per transaction. Given the diverse circumstances of beneficiaries, a one-size-fits-all approach based on single prescription thresholds could significantly restrict access to the MPPP for those who might benefit from it the most. Recognizing the varied financial situations of Medicare beneficiaries, the NHC recommends a more inclusive criterion that considers cumulative OOP costs to ensure that all beneficiaries who could benefit from the MPPP are adequately informed and supported. To ensure comprehensive beneficiary support, the NHC requests that CMS direct Part D sponsors to conduct targeted outreach for beneficiaries whose total OOP costs within a defined recent period reach the established eligibility threshold. This broader approach would help identify beneficiaries taking multiple lower-cost medications that cumulatively impose significant financial burdens, ensuring they are not inadvertently excluded from benefiting from the MPPP. Such targeted outreach should complement the existing mechanisms, bridging the gap to include a wider range of beneficiaries potentially eligible for the program and fostering more inclusive and informed decision-making among the Medicare population. Moreover, while the NHC appreciates the requirement for pharmacies to inform the Part D enrollees about the MPPP upon receiving a notification, we call for additional support and resources for pharmacies to ensure these conversations are as informative and helpful as possible. Given the complexity of the MPPP and its potential impact on enrollees’ health care decisions, it is vital that pharmacies are equipped with comprehensive, easy-to- understand information that can be readily shared with enrollees. This support could include detailed FAQs, training sessions for pharmacy staff, and clear guidelines on how to handle enrollees’ questions or direct them to further assistance.

The NHC recognizes the essential role of pharmacies and health care providers in facilitating informed discussions regarding prescription drug costs with Medicare beneficiaries, and we support CMS’ directive for Part D sponsors to alert pharmacies when a beneficiary’s OOP costs for covered Part D drugs reach a threshold that suggests they might benefit from the MPPP. This provision ensures timely and crucial information is relayed to beneficiaries at a critical decision-making juncture, potentially alleviating the financial burden of prescription medications. Furthermore, the encouragement for Part D sponsors to engage in targeted communication with health care providers, particularly those in specialties more likely to prescribe high-cost medications, is a proactive approach to ensure that the prescribers are also aware of the MPPP and can guide their patients accordingly. However, the NHC recommends that CMS consider additional measures to enhance the effectiveness of these communications. Specifically, CMS could develop standardized training or informational sessions for pharmacy staff and health care providers to ensure they have a comprehensive understanding of the MPPP. This training could include case studies, FAQs, and scenarios to better prepare them for patient inquiries and to facilitate more meaningful discussions about the program. Moreover, the NHC suggests that CMS explore the development of digital tools or platforms that could assist pharmacies and providers in identifying eligible beneficiaries more efficiently and in providing personalized information about the benefits of enrolling in the MPPP. These tools could integrate with existing systems such as real-time benefit tools to flag eligible patients automatically and provide tailored information based on the patient’s medication regimen and financial situation.

  • Communications with Program Participants and Model Materials Requirements for Part D Sponsors

The NHC acknowledges CMS’ comprehensive approach to offering election options and the emphasis on providing additional information to enrollees to ensure they fully understand the financial implications of participating in the MPPP. The NHC strongly supports the provision that allows Part D enrollees to opt into the MPPP at any point during the plan year or during enrollment periods, which offers flexibility and ensures that beneficiaries can benefit from the program when they need it most. However, the NHC believes that further clarification and guidance on the process for electing to participate in the MPPP would be beneficial. Specifically, clear, straightforward instructions on how to opt into the program through various methods (paper, telephone, and website) should be provided to ensure the process is accessible to all, especially those with limited technological skills or access. Moreover, the NHC recommends that Part D sponsors not only provide estimates of monthly payments under the MPPP but also offer additional tools and resources, such as decision aids or interactive online platforms such as a monthly cost calculator, to help beneficiaries understand how the program affects their specific situation, particularly for those with complex medication needs or those considering the MPPP alongside other assistance programs like LIS. This personalized approach can help prevent confusion and ensure beneficiaries make informed decisions based on their unique circumstances. Finally, the NHC underscores the importance of clear communication regarding the LIS program as an alternative or additional avenue for managing prescription drug costs. Given that LIS enrollment might offer more benefits for those who qualify, it’s crucial that Part D sponsors effectively inform enrollees about their options. The NHC suggests that CMS develops and provides resources, model language, training, and support to Part D sponsors to ensure these communications are as clear and effective as possible, thus enabling beneficiaries to navigate their options with confidence.

The NHC appreciates CMS’ initiative in developing model documents to assist Part D plan sponsors and Medicare Advantage (MA) organizations satisfy the education and outreach responsibilities for Part D sponsors and MA organizations for the MPPP in: 1) the likely to benefit notice (“Consider Managing Your Monthly Drug Costs with the Medicare Prescription Payment Plan”), 2) the election request form (“Medicare Prescription Payment Plan participation request form”), 3) the notice of election approval (“Part D Sponsor Notice to Acknowledge Acceptance of Election to the Medicare Prescription Payment Plan”), 4) the notice of failure to pay (“Part D Sponsor Notice for Failure to Make Payments under Medicare Prescription Payment Plan”), 5) the notice of involuntary termination (“Part D Sponsor Notice for Failure to Make Payments under Medicare Prescription Payment Plan”), and 6) the notice of voluntary termination (“Part D Sponsor Notification of Voluntary Removal from the Medicare Prescription Payment Plan”). These model documents are critical tools to ensure that enrollees are well-informed about and can seamlessly opt into or out of the MPPP, enhancing patient-centered care and access to affordable prescription medications. The NHC is reviewing these documents and intends to submit detailed feedback to CMS, but generally, to ensure that the MPPP is accessible, understandable, and beneficial to all Part D enrollees, we propose the following recommendations for CMS:

  1. Enhance form accessibility and inclusivity: Ensure all forms, across all election methods, are designed with accessibility in mind, ensuring usability by individuals with various disabilities, including visual, auditory, and cognitive impairments, uses clear, jargon-free language accessible to enrollees with varying levels of health literacy, and made available in multiple languages to accommodate the diverse Medicare population, including those with LEP.
  2. Establish a robust support system for enrollees: Provide comprehensive guidance on the impact the MPPP’s impact on prescription drug costs and personalized assistance to help enrollees make informed decisions, extending beyond the initial request to participate, encompassing ongoing education about the program’s benefits, potential changes, and how enrollees can maximize its
  3. Ensure prompt and proactive sponsor communication: Part D sponsors should be required to actively collect any missing information and confirm enrollees’ understanding of the program’s terms and conditions, particularly when enrollees submit election requests in non-standard formats.
  4. Monitor and evaluate the effectiveness of the election process: Identify and address any barriers that enrollees might face in opting into the MPPP to ensure a smooth enrollment experience.
  5. Test model documents with diverse user groups: Ensure documents are understandable, meet the needs of all potential enrollees, and widely available and easily accessible in diverse settings, including but not limited to community centers, health care facilities, and, for paper election requests, through direct mail options to reach those without internet access. Digital election requests should be user-friendly, accessible, and compliant with the latest web accessibility standards.
  6. Provide detailed instructions and support for paper forms: Part D sponsors should be required to offer detailed instructions and support services, such as a dedicated helpline, for completing paper forms. This assistance should be available in multiple languages and accessible formats to accommodate all enrollees, including those with visual or cognitive impairments.
  7. Incorporate safeguards against inadvertent disenrollment: Develop and disseminate clear, step-by-step guidance for beneficiaries on how to initiate an appeal if they are involuntarily disenrolled from the MPPP before termination and information on support services for financial difficulties. It is crucial for this guidance to be accessible in various formats and languages to accommodate all beneficiaries. Additionally, the NHC advocates for compassionate consideration of individual circumstances in both notices and urges CMS to incorporate provisions for hardship exceptions or extended grace periods in certain situations. This approach should balance the need for financial policies with the protection of vulnerable beneficiaries, ensuring the process is supportive, informative, and considers beneficiaries’ financial vulnerabilities.

Furthermore, given the complexity of health care information and the diverse needs of Medicare beneficiaries, the NHC recommends that CMS issue guidance to Part D sponsors on employing a variety of communication methods beyond the required telephonic and written notices. This could include informational videos, interactive online Q&A sessions, and community outreach events to educate beneficiaries about the MPPP and ensure they fully understand the implications of their election decisions.

While the NHC commends the steps to notify beneficiaries of their election into the MPPP outlined in the draft Part Two guidance, we encourage CMS and Part D sponsors to continue seeking ways to enhance beneficiary communications. By making information more accessible, understandable, and actionable, we can ensure that all beneficiaries are well-equipped to make informed decisions about their participation in the MPPP. By addressing these considerations, CMS and Part D sponsors can ensure that the process for voluntary termination from the MPPP is transparent, patient- centered, and aligned with the best interests of Medicare beneficiaries.

  • Language Access and Accessibility Requirements

The “Language Access and Accessibility Requirements” outlined in the draft Part Two guidance are critically important for ensuring that all Part D enrollees, particularly those with LEP and diverse cultural and ethnic backgrounds, can access and understand information about the program. The NHC commends CMS for its commitment to providing materials in a culturally competent manner and for requiring Part D sponsors to adhere to these crucial standards.

The NHC appreciates the emphasis on making all vital information related to enrollment, benefits, health, and rights available in multiple languages and accessible formats. This approach is fundamental to removing barriers to information and ensuring that every beneficiary has the opportunity to make informed decisions about their health care. The requirement for Part D sponsors to provide translated materials in any non-English language that is the primary language of at least five percent of individuals in a Plan Benefit Package (PBP) service area is a step in the right direction towards addressing health disparities and promoting equity in health care access.

Moreover, the NHC supports the inclusion of multi-language inserts (MLIs) in CMS- required materials, which inform beneficiaries about the availability of free interpreter services. This is an essential tool for beneficiaries who may not be proficient in English or who prefer to receive health care information in their primary language. It is crucial that these MLIs are prominently placed in all relevant materials to ensure they are easily noticed by those who need them.

The NHC also recognizes the importance of compliance with anti-discrimination provisions, such as Section 508 of the Rehabilitation Act, which requires Part D sponsors’ websites and materials to be accessible to individuals with disabilities. Ensuring that websites and materials are compatible with screen reader technology and other auxiliary aids is vital for providing equal access to information for all beneficiaries, including those with visual impairments or other disabilities.

However, the NHC believes that beyond compliance, there should be a proactive effort to engage with communities that have historically been underserved or face language barriers. This could include partnerships with community organizations, health care providers, and advocacy groups to disseminate information about the MPPP in a manner that is culturally and linguistically tailored to the needs of diverse communities.

Furthermore, the NHC suggests that CMS and Part D sponsors consider the use of visual aids, infographics, and video materials that can transcend language barriers and provide an intuitive understanding of the MPPP. Such materials can be particularly effective in conveying complex information in a more digestible format, potentially increasing program comprehension and engagement among beneficiaries with varying literacy levels.

Related to these requirements, the NHC seeks clarity on how pharmacies, especially in the context of distributing the MPPP “Likely to Benefit” notice, will navigate language access obligations. It is imperative that the final guidance specifies whether these responsibilities extend to pharmacies and delineates how they should determine the appropriate language(s) for communication, ensuring inclusivity and accessibility for all beneficiaries.

40.   CMS Part D Enrollee Education and Outreach

The NHC commends CMS for recognizing the critical need to provide comprehensive educational materials to Part D enrollees about the MPPP. Ensuring broad education on the program’s availability is essential for empowering beneficiaries to make informed health care decisions. Overall, we feel CMS still needs to be clearer on how it will develop new, standardized educational resources and update existing ones to include information about the MPPP. Additional clarity will greatly assist the patient advocacy community in understanding what CMS will do – and what our community must do – to raise awareness among Part D enrollees.

  • Information on the Medicare Prescription Payment Plan

The NHC supports the development of educational resources for Part D enrollees, available on the Medicare.gov website and other communication channels. CMS’ inclusion of various stakeholders, such as Part D sponsors, pharmacies, providers, and beneficiary advocates, in using and disseminating this product is a commendable approach that will ensure a wide reach of the program’s information.

The requirement for Part D sponsors to use this educational product on their websites, in membership ID card mailings, and alongside the “Medicare Prescription Payment Plan Likely to Benefit Notice” is a strategic approach to ensure consistent messaging across different communication mediums. This requirement will help streamline information dissemination and ensure that enrollees have multiple touchpoints to learn about the MPPP.

The encouragement for Part D sponsors to provide additional information to pharmacies and to communicate with contracted providers and other interested parties using the educational product will foster a collaborative environment. It ensures that all parties involved in beneficiary care are well-informed about the MPPP, facilitating better support for enrollees considering the program.

However, the NHC suggests that CMS consider involving patient advocacy groups and beneficiaries in the development of these educational materials to ensure they are patient-centered and address the real-world concerns and questions of enrollees.

Additionally, the NHC recommends that CMS develop interactive and user-friendly tools, such as cost calculators or decision aids, to accompany the educational product, providing enrollees with practical resources to assess their potential benefits from the MPPP.

  • Modifications to Existing Part D Resources

The NHC appreciates CMS’ commitment to modifying existing Medicare Part D documents, web content, and tools to include information about the MPPP. This approach ensures that beneficiaries have access to updated and comprehensive resources to understand the program’s potential benefits relative to their individual needs.

The inclusion of information about the MPPP in widely used resources such as the Medicare & You Handbook, Medicare.gov, and the Medicare Plan Finder will significantly enhance program visibility and understanding among enrollees. The NHC encourages CMS to offer greater clarity on how the Agency will do this and how you will ensure that these modifications are made in an easily understandable manner, catering to the diverse literacy levels and language needs of the Medicare population.

  • National Outreach and Education Efforts

The NHC supports CMS engagement with a diverse array of stakeholders, including State Health Insurance Assistance Program (SHIP) counselors, to improve national outreach and education efforts for the MPPP. This collaborative approach is crucial for disseminating accurate, comprehensive information about the program widely, especially to those who may benefit the most from the program. To further enhance outreach and education efforts, the NHC recommends that CMS integrate patient perspectives into the creation of educational materials and interactive tools by engaging Medicare beneficiaries, experts in health literacy and cultural competence, and the patient community, in discussions to guide the creation of educational content and interactive tools. These trusted messengers can assist CMS incorporate real-life scenarios and FAQs to make these resources resonate more with beneficiaries.

Additionally, by leveraging relationships with trusted messengers within communities, CMS can overcome barriers to information access and understanding, further broadening the program’s reach as it implements targeted outreach initiatives to reach vulnerable populations who may face barriers to accessing program information.

The NHC appreciates CMS’ outlined approach in providing beneficiaries with essential information to make informed health care decisions. We encourage the continued development and broadening of these efforts, focusing on tailoring information dissemination to match the preferred communication methods of beneficiaries, whether in-person, digital, telephonic, or otherwise. By ensuring messages are consistent across platforms, and tools are readily accessible in various formats, CMS can minimize confusion and boost program engagement, facilitating a more straightforward decision- making process for all beneficiaries.

50.   Pharmacy Processes

Given the complexity and breadth of the “Pharmacy Processes” section in the draft Part Two guidance of the MPPP, the NHC appreciates the emphasis on the pivotal role pharmacies play in operationalizing the MPPP and agrees with the requirement for Part D sponsors to notify pharmacies when a Part D enrollee’s OOP costs indicate potential eligibility for the MPPP. The NHC supports the mandate for pharmacies to inform Part D enrollees about the MPPP upon notification from Part D sponsors, highlighting the importance of direct communication in enhancing enrollee awareness and participation in the program. However, the NHC continues to urge CMS to work with pharmacies and pharmacists to implement POS enrollment in the MPPP as soon as possible.

  • Part D Enrollees with Supplemental Coverage that Modifies the Final Patient Pay Amount

The NHC recognizes the complexity introduced by supplemental coverage and appreciates CMS’ acknowledgment of how such coverage can impact the final patient pay amount, potentially affecting the enrollee’s perceived benefit from the MPPP. We recommend that CMS provide clear and detailed guidance for Part D sponsors and pharmacies on handling cases with supplemental coverage, ensuring that enrollees receive accurate information about their potential benefits from the MPPP.

  • Pharmacy POS Notifications Late in the Plan Year

The NHC is concerned about scenarios where late-year notifications could lead to enrollees being required to pay the full amount as part of their first month’s bill under the MPPP and suggests exploring mechanisms to adjust the billing in such cases to prevent financial hardship for enrollees opting into the program late in the plan year.

  • Pharmacy POS Notifications in Retail and Non-Retail Pharmacies

The NHC encourages CMS to ensure offering of the “Medicare Prescription Payment Plan Likely to Benefit Notice” to enrollees at the POS in pharmacies with direct enrollee contact is implemented smoothly across all pharmacy settings to maximize enrollee engagement and understanding. For pharmacy settings without direct enrollee contact, the NHC appreciates CMS’ efforts to provide guidance and encourages the development of innovative strategies to ensure enrollees receive timely and effective notifications. The NHC acknowledges the unique challenges presented by long-term care pharmacies and supports CMS’ approach to allow flexibility in the provision of the “Likely to Benefit Notice” within these settings. We encourage continued dialogue with stakeholders in the long-term care sector to ensure that enrollee notifications are handled appropriately and effectively. The NHC recognizes the special considerations necessary for Indian Health Services (IHS), Tribe and Tribal Organization, and Urban Indian Organization (I/T/U) pharmacies and supports the exemption from the requirement to notify the pharmacy of an enrollee’s potential eligibility for the MPPP. We suggest that CMS and Part D sponsors engage with I/T/U pharmacies to ensure that IHS-eligible Part D enrollees are aware of the MPPP and understand how their coverage through I/T/U pharmacies interacts with the program. For pharmacies without in-person encounters, such as mail-order pharmacies, the NHC appreciates CMS’ guidance on alternative notification methods. However, clarity is also needed regarding online or digital-focused pharmacies. For example, clarity on whether these pharmacies must send hard copy notifications in addition to digital notices at the POS is needed.

Furthermore, the implementation challenges posed by digital transactions, where prescription selection and payment are simultaneous, necessitate clear CMS guidance to prevent any disruption in beneficiary experience.

We encourage CMS to collaborate with Part D sponsors to ensure that these methods are effective in reaching enrollees and providing them with the necessary information to make informed decisions about the MPPP.

  • Readjudication of Prescription Drug Claims for New Program Participants

The NHC supports the process for the readjudication of prescription drug claims to ensure that new program participants pay $0 at the POS for covered Part D drugs. We recommend clear communication and guidelines for pharmacies to ensure this process is conducted smoothly and without undue burden on the enrollee.

  • Processing of Covered Part D Claims for Program Participants in Special Settings

The NHC acknowledges the complexity of processing Part D claims for beneficiaries in special settings, such as long-term care facilities and I/T/U pharmacies. The unique billing arrangements and the potential financial implications for participants in these settings necessitate careful consideration and tailored approaches to ensure that beneficiaries’ interests are safeguarded.


 The NHC appreciates the opportunity to comment on the draft Part Two guidance. Please do not hesitate to contact Eric Gascho, Senior Vice President of Policy and Government Affairs, if you or your staff would like to discuss these comments in greater detail. He is reachable via e-mail at [email protected].

Randall L. Rutta
Chief Executive Officer

1 Centers for Medicare & Medicaid Services. (2023). Maximum monthly cap on cost-sharing payments under prescription drug plans: draft part one guidance on select topics, implementation of Section 1860D- 2 of the Social Security Act for 2025, and solicitation of comments. Retrieved from https://www.cms.gov/files/document/medicare-prescription-payment-plan-part-1-guidance.pdf

2 National Health Council. (2023). NHC comments on maximum monthly cap on cost-sharing payments. Retrieved from https://nationalhealthcouncil.org/wp-content/uploads/2023/09/NHC-MPPP-Comments.pdf