Key Takeaways from the 2024 MA Final Rule

On April 5th, the Centers for Medicare & Medicaid Services (CMS) released their 2024 Final Rule concerning Medicare Advantage, a move that will help put an end to deceptive marketing tactics, simplify prior authorization procedures and open up much-needed access to behavioral healthcare. Furthermore, this pivotal regulation is striving towards health equity by introducing policies from the Inflation Reduction Act which substantially decrease prescription drug prices. Let's dive deeper into what these critical changes are designed to do.

Curb Deceptive Marketing Tactics, Guaranteeing Authenticity and Transparency

CMS is committed to shielding seniors from advertising practices that are confusing and misleading when it comes to Medicare Advantage and Part D coverage. That's why they're prohibiting ads without a specific plan name or if they use the government-issued products, logo, or information in an ambiguous way. This change was brought on by the rise of certain TV commercials promoting enrollment in MA plans with language which could be misunderstood by beneficiaries.

In order to better protect beneficiaries and guarantee they receive accurate information concerning Medicare coverage, CMS has finalized a rule that increases accountability for plans monitoring agent and broker activity. Of the 22 provisions proposed in December, 21 were finalized with 17 of those being implemented as written; however, four had modifications made before their implementation. According to an official fact sheet released by CMS, this new ruling will ensure beneficiary safety is upheld while simultaneously increasing transparency across all levels of healthcare operations.

Agents are now able to offer business reply cards at educational events, and must inform prospective enrollees of all plan options provided by the company for which they work. Additionally, agents have been granted permission to recontact beneficiaries with regard to plans within a 12-month period. Furthermore, if 48 hours has passed without an agent being able to meet up with a beneficiary due either transportation or access challenges or because the election period is coming to an end soon - not considering when it's on their own accord in walking into the office - then that time requirement will be waived as well. CMS announced its determination to further research the provision not included in this rule through potential upcoming regulations.

Eliminate Obstacles to Care Caused by Complicated Processes

The new ruling simplifies prior authorization specifications and reduces interruption for those enrolled by ensuring that approved authorizations remain valid until medically necessary to avoid ceasing care. Additionally, MA plans must review their utilization management regulations annually, with health professionals familiar with the subject matter having final say on denials based on medical necessity before a denial is issued. These policies are complementary to CMS' Advancing Interoperability and Improving Prior Authorization Processes Proposed Rule.

To make sure that MA (Medicare Advantage) enrollees obtain the same clinically necessary care they would acquire in traditional Medicare, CMS has added significant protections regarding utilization management policies and coverage criteria. This initiative complies with current Office of Inspector General's recommendations. To ensure that MA plans meet quality criteria for basic benefits, CMS mandates compliance with both national coverage determinations (NCD) and local coverage determinations (LCD), in addition to the general conditions of Medicare regulations.

If the coverage criteria is not definitively laid out, Medicare Advantage organizations have permission to create internal qualifications based on existing evidence found in publicly available treatment guidelines and clinical literature. Additionally, CMS has more clearly defined the conditions under which MA plans can apply interval coverage criteria when assessing medical necessity decisions. The agency has declared that authorizing the use of publicly accessible internal coverage criteria in specific circumstances is essential to create transparent and evidence-based clinical decisions by MA plans, which must be equivalent with traditional Medicare.

Furthermore, CMS finalized the rule that simplifies prior authorization prerequisites and adds continuity of care requirements to reduce disruptions for beneficiaries. The use of coordinated care plan prior authorization is only necessary to confirm a diagnosis or other medical criteria, as well as ensure any item or service is medically required. When an enrollee who is currently undergoing treatment transitions to a new MA plan, it necessitates that coordinated care plans ensure at least 90 days of uninterrupted therapy. During this transition period, the new MA plan must not demand authorization for active court of treatment either.

To guarantee that prior authorization is utilized correctly, CMS demands all MA plans to form a utilization management committee to review policies annually and ensure uniformity with Medicare's customary national and local coverage decisions as well as standards. To ensure that the "course of treatment" is defined in a clear manner, the final rule mandates that prior authorization requests must be approved for as long as medically necessary to avoid interruptions in care and are based on applicable coverage criteria, patient medical history and treating provider recommendations.

Widen Access to Behavioral Health Care Services

To enhance the quality of MA's behavioral health services, clinical psychologists and licensed clinical social workers have been added to the list of evaluated specialties. Additionally, these specialty types will be granted a 10-percentage point telehealth credit. Furthermore, wait time standards for both primary care services and behavioral health services have been set in place by CMS along with more defined notice requirements from plans when certain providers are dropped from their networks.

Furthermore, the CMS will mandate that most MA plans include behavioral health services in their care coordination programs to ensure that mental wellbeing is a key element of individual-focused healthcare planning.

Promote Health Equity and Opportunity for All

Dedicated to promoting health equity for all, CMS has reaffirmed their commitment to providing access and support towards those who have been traditionally neglected or mistreated due to poverty and inequality. The agency is furthering its current regulations by expanding the list of populations requiring culturally competent services from MA organizations, these include Individuals and groups with diverse backgrounds, including those from ethnic or cultural minorities, members of the LGBTQ+ community, people with disabilities, limited English proficiency or reading skills; as well as those residing in rural areas suffering from poverty and inequality are disproportionately affected.

CMS has recognized that a lack of digital health literacy, particularly among those most affected by health disparities, continues to hinder telehealth access which ultimately widens the care gap. To address this issue, CMS is requiring MA plans to develop procedures offering digital education to enrollees in order to improve access to medically necessary covered benefits. Additionally, they are enhancing current best practices through mandating MA organizations incorporate providers’ cultural and linguistic capabilities when creating provider directories.

According to the agency, this shift will raise provider directory quality and efficiency - particularly for non-English speakers, limited English proficient people, and those who use American Sign Language. Furthermore, CMS has decreed that MA plans must make strides in their Quality Improvement Programs in order to reduce disproportionality.

The Inflation Reduction Act's New Prescription Drug Law Now in Effect

To ensure better access to affordable prescription drug coverage for nearly 300,000 low-income individuals, the Inflation Reduction Act's pivotal rule is being implemented. The full low-income subsidy benefit (commonly called "extra help") will be granted to those who are eligible and whose incomes fall under 150 percent of the federal poverty level.

Effective January 1, 2024, eligible enrollees will reap the benefits of full low-income subsidies without any deductible or premiums (if enrolled in a benchmark plan). Moreover, to help reduce copayments for certain medications under Medicare Part D, they will receive fixed and lowered costs as well.

Make Exceptional Improvements to Star Ratings

The CMS has settled on novel methodologies to its Star ratings program in order to fortify quality healthcare. Starting with the 2027 Star Ratings, such alterations include a Health Equity Index Reward that will compensate Medicare Advantage and Part D plans for providing distinguished care towards underserved populations, while also demanding those same plans administer culturally competent care toward an extended list of patients. Furthermore, they must grant equitable access to those who possess limited English proficiency through special materials written in alternate formats and languages.

To ensure consistency among other CMS initiatives and the current Quality Strategy, CMS has reduced the impact of patient experience/complaint metrics and access measures. Moreover, a new rule was added to eliminate Star rating requirements while simultaneously repealing the 60 percent regulation associated with extreme cases beyond anyone's control.

The agency declared that the last rule harmonizes patient experience and observant measures, access measures, and health outcomes measurements in the Star rating program to concentrate more effectively on attending to patients' needs and elevating clinical results.

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Blog by: The ForeSee Medical Team