With the annual Medicare Advantage (MA) open enrollment well underway (October 15th – December 7th each year), it’s the perfect time to revisit the significant changes outlined in the Centers for Medicare & Medicaid Services (CMS) 2024 Medicare Advantage and Part D Final Rule (CMS-4201-F).1 With a strong emphasis on equity and access to healthcare, these adjustments aim to protect beneficiaries, strengthen quality measures, and advance health equity for all Medicare recipients.
In this two-part blog post, we’ll explore the key provisions of the final rule and their implications for healthcare payers.
Utilization Management Requirements: Ensuring Timely Access to Care:
To ensure that beneficiaries have timely access and continuity of care, the CMS final rule includes various utilization management (UM) requirements changes. These changes include requiring:
- MA plans must comply with national coverage determinations (NCDs), local coverage determinations (LCDs), and general coverage and benefit conditions included in Traditional Medicare regulations to ensure that people with MA receive access to the same medically necessary care they would receive in Traditional Medicare.
- Coordinated care plan prior authorization policies may only be used to confirm the presence of diagnoses or other medical criteria and/or ensure that an item or service is medically necessary.
- Coordinated care plans to provide a minimum 90-day transition period when an enrollee currently undergoing treatment switches to a new MA plan, during which the new MA plan may not require prior authorization for the active course of treatment.
- All MA plans to establish a utilization management committee to review policies annually and ensure consistency with Traditional Medicare’s national and local coverage decisions and guidelines.
- Approval of a prior authorization request for a course of treatment must be valid for as long as medically reasonable and necessary to avoid disruptions in care by applicable coverage criteria, the patient’s medical history, and the treating provider’s recommendation.
These changes could create challenges for payers, as they may need to invest in new technologies and services, such as clinical decision support systems and automated prior authorization systems, to comply with the new UM requirements and improve the timeliness of care for their enrollees.
In addition to investing in new technology, payers can mitigate the challenges of the new UM requirements by communicating with providers and monitoring and evaluating their performance. By working with providers to understand the new requirements and tracking how long it takes to get prior authorization approvals, payers can identify and address any areas of improvement.
Marketing Requirements: Protecting Beneficiaries
The CMS final rule includes changes to marketing requirements to protect beneficiaries from misleading or confusing information and ensure they can make informed decisions about their coverage. These changes include:
- Prohibiting ads that do not mention a specific plan name and use words and imagery that may confuse beneficiaries or use language or Medicare logos in a way that is misleading, confusing, or misrepresents the plan.
- Ensuring that Medicare recipients receive accurate information about Medicare coverage and know how to access accurate information from other available sources.
These new marketing requirements could make it more difficult for payers to reach potential enrollees. Payers may need to revise their marketing materials and strategies to comply with the new requirements. They may also need to invest in new training for their marketing staff.
Star Rating Program Improvements: Strengthening Quality
In pursuit of elevated quality standards and greater equity, the Medicare Star Rating Program updates encompass:
- Finalizing a health equity index (HEI) reward, beginning with the 2027 Star Ratings, to further encourage MA and Part D plans to improve care for enrollees with certain social risk factors.
- Reducing the weight of patient experience/complaints and access measures to further align with other CMS quality programs and the current CMS Quality Strategy.
- Removing Star Rating measures and removing the 60 percent rule is part of the adjustment for extreme and uncontrollable circumstances.
These new Star Rating Program changes could make it more difficult for payers to achieve high Star Ratings. However, they will also help ensure that plans focus on the most important quality measures. Payers may need to adjust their quality improvement strategies to comply with the new Star Rating Program requirements. They may also need to invest in new data collection and analysis capabilities to track their performance on the new measures.
Advancing Health Equity
To ensure that all beneficiaries have access to high-quality care, MA and Part D programs are required to implement changes to advance health equity. These modifications include:
- Clarifying current rules and expanding the example list of populations that MA organizations must provide services in a culturally competent manner.
- Finalizing requirements for MA organizations to develop and maintain procedures to offer digital health education to enrollees to improve access to medically necessary covered telehealth benefits.
- Enhancing current best practices by requiring MA organizations to include providers’ cultural and linguistic capabilities in provider directories.
- Requiring that MA organizations’ quality improvement programs include efforts to reduce disparities.
The new health equity requirements will significantly impact payers, affecting costs, operations, and staffing levels, and aid in payer-provider collaborations. Compliance may necessitate investment in digital health education, cultural competency training for providers, provider directories, and new data collection/reporting systems to track social risk factors and health outcomes. Payers must also update quality improvement programs to address care disparities, potentially requiring the development of new interventions and progress tracking.
Navigating the CMS Final Rule Changes
Stay tuned for part two, where we will continue to look at key provisions in the CMS final rule and how they will impact payers. Together, we can navigate these changes and delivering the care that Medicare beneficiaries deserve. All while upholding the standards of affordability and quality in healthcare services.
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Source:
1. Fact sheet 2024 Medicare Advantage and Part D Final Rule (CMS-4201-F), CMS
