The Centers for Medicare and Medicaid Services (CMS) recently released a final rule for Medicare Advantage plans (MA) and the Medicare Prescription Drug Benefit Program for calendar year (CY) 2024.
The rule increases oversight of MA plans and seeks better alignment with Medicare fee-for-service (FFS), including clarifying that MA plans cannot use clinical criteria guidelines that are more restrictive than Medicare FFS to ensure that MA beneficiaries receive access to the same medically necessary care which is increasingly important as enrollment in MA continues to grow.
As recently reported, 59% of Michigan’s total Medicare beneficiaries are enrolled in an MA plan, with enrollment by county ranging from 42% to 75%. The final rule:
- Prohibits MA plans from limiting or denying coverage for a Medicare-covered service based on their own internal or proprietary criteria if such restrictions do not exist under Medicare FFS.
- Explicitly states that MA plans must adhere to the Two-Midnight Rule, the Inpatient Only List and case-by-case expectation criteria that apply for Medicare FFS.
- Prohibits MA plans from denying coverage or redirecting post-acute care to a lower level unless the patient explicitly does not meet the Medicare coverage criteria required for the recommended level of care.
- Explicitly states that MA plans must provide both coverage and payment for care provider to stabilize an emergency medical condition determined using the prudent layperson standard regardless of the final diagnosis.
- Requires health plan physician or other professionals to have expertise in the field of medicine related to the service being requested in the prior authorization (PA).
- Requires PAs to be valid for an entire course of approved treatment and provide a minimum 90-day transition period if an enrollee undergoing treatment switches to a new MA plan.
- Establishes additional processes to oversee MA plan utilization management programs including an annual review of policies to ensure compliance with Medicare rules and consistency with current clinical guidelines.
- Strengthens behavioral health network adequacy requirements in several ways:
- MA plans are currently required to provide access to an adequate network of “appropriate providers”, including primary care physicians, specialists, hospitalists and others. Plans are also required to demonstrate that the network includes an adequate number of psychiatrists and inpatient psychiatric facilities. This rule adds providers that specialize in behavioral health services to this list, including clinical psychologists and licensed clinical social workers.
- Codifies standards for appointment wait times for primary care and behavioral health services.
- Clarifies that emergency behavioral health services are not subject to PA.
- Requires MA plans to notify enrollees when the enrollee’s behavioral health or primary care provider is dropped from the network mid-year.
- Amends general access to services standards to explicitly include behavioral health services.
- Requires MA plans to establish care coordination programs to increase parity between behavioral and physical health services.
- Restricts MA plan marketing practices to protect beneficiaries from misleading advertisements and pressure tactics designed to increase enrollment.
- Expands requirements for MA plans to provide culturally and linguistically appropriate services.
- Establishes a new Health Equity Index to be incorporated into the MA plan Star Ratings beginning in 2027 to improve performance for patients with certain social risk factors.
- Implements statutory provisions of the Inflation Reduction Act and the Consolidated Appropriations Act of 2021 related to the prescription drug affordability and coverage for eligible low-income individuals.
The CMS indicates that it intends to release a second rule to address remaining proposals from the December 2022 proposed rule that were not addressed in this rule, with the second rule to have a later effective date, expected to be no earlier than Jan. 1, 2025.
Members with questions should contact Vickie Kunz at the MHA.