Part B: CSRO Urges Support of Complex Therapies Act
In letters to eight Senate Democrats, CSRO urged members of Congress to become original cosponsors of the Protecting Patient Access to Cancer and Complex Therapies Act (H.R.4299), which will allow the add-on payment for Part Badministered medications to remain at ASP + 6% instead of the Maximum Fair Price (MFP) + 6%, as outlined in the CY 2026 Fee Schedule. CSRO is concerned about the erosion of the add-on payment and physician reimbursement that may put private practices underwater for selected drugs, thus making access to these medications more difficult for patients. In letters to Sens. Kelly (AZ), Duckworth (IL), Klobuchar (MN), Heinrich (NM), Lujan (NM), Booker (NJ), Kim (NJ) and Fetterman (PA), CSRO expressed support for this critical legislation that would remove physician Part B drug reimbursement from the middle of Medicare Drug Price Negotiation Program (MDPNP) negotiations while maintaining the savings secured under the Inflation Reduction Act for the federal government and Medicare beneficiaries.
CMS Releases CY 2027 MA, Part D Proposed Rule
CMS recently published the CY 2027 Medicare Advantage (MA) and Part D proposed rule, which includes a broad set of policy, operational, and programmatic changes with implications for rheumatology practices and patients. The proposal includes regulatory amendments to codify Inflation Reduction Act (IRA) policies implemented through program instructions, including the CY 2025 and CY 2026 Part D redesign and Manufacturer Discount Program guidance, along with related technical corrections affecting the Part D benefit, coverage gap, and manufacturer discount programs.
For MA and Part D operations, CMS proposes to streamline and rename the Special Enrollment Period (SEP) for provider terminations and to clarify which SEPs require CMS approval, an issue of particular concern for rheumatology given ongoing network adequacy challenges and recent terminations of rheumatologists from MA networks. CMS also proposes changes affecting enrollment and marketing oversight, including new disclaimer requirements for third-party marketing organizations (TPMOs), eliminating certain marketing time and manner restrictions, and relaxing certain advertising language requirements, all of which raise questions about how beneficiary protections will be maintained.
The rule also proposes significant changes to the Star Ratings program, including removal of 12 operational, process, and patient experience measures - notably Complaints about the Health/Drug Plan and important appeals-related measures (i.e., Plan Makes Timely Decisions about Appeals and Reviewing Appeals Decisions). These measures have historically served as important tools to identify access barriers, inappropriate denials, and misleading marketing practices affecting beneficiaries.
Additional proposals include changes aimed at reducing regulatory burden, revisions to utilization management and quality improvement requirements, codification of opioid outlier prescriber provisions under the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act, and clarifications related to Special Supplemental Benefits for the Chronically Ill (SSBCI). CMS also seeks public input through multiple requests for information (RFIs) on risk adjustment, quality bonus payments, dual-eligible enrollment growth, well-being and nutrition, and plan marketing practices, including network adequacy and supplemental benefit utilization, providing key opportunities for the rheumatology community to reiterate longstanding access and oversight concerns.
Additional details are available in CMS’ fact sheet on the proposed rule. CSRO is preparing formal comments on the rule and seeks input from state societies and rheumatology practices, including examples of how MA and Part D policies are affecting rheumatology practices and patient access to care. Please share experiences by January 2 so they can be incorporated, as appropriate, into CSRO’s written response.
CMS Finalizes Maximum Fair Prices for Certain Part D Drugs in 2027
CMS announced the next group of 15 drugs selected for the Medicare Drug Price Negotiation Program (MDPNP), with Maximum Fair Prices (MFPs) taking effect January 1, 2027. Of note for rheumatology, the Initial Price Applicability Year 2027 (IPAY 2027) list includes Otezla (apremilast), which is used to treat psoriatic arthritis. Importantly, CMS’ drug selection methodology for the MDPNP excludes certain biologics once there is a commercially available generic or biosimilar product available. As such, Stelara (ustekinumab) is no longer subject to negotiated pricing for 2027. Additional details are available in CMS’ fact sheet, infographic, and MDPNP webpage.
Kick off the year with CSRO’s virtual State Policy Update, highlighting key priorities and trends for the 2026 legislative session. Hear from our government affairs team about upcoming policies affecting private practice, reimbursement, and patient access—and how you can advocate effectively. Register here!
Join us in Washington, D.C. for CSRO’s flagship Advocacy Conference to learn, network, and strategize around patient access to care. Sign up for the Registration Launch here!
State Society Conferences: CSRO's state rheumatology society members host their own annual meetings throughout the year. Find a listing of these state-specific conferences on our website.
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