The Centers for Medicare & Medicaid Services (CMS) on Wednesday released the 2024 Medicare Advantage Final rule, making good on its promise to crack down on misleading marketing schemes, streamline the prior authorization process, and expand access to behavioral health care.
The 724-page final rule, which is scheduled to be published in the Federal Register on April 12, revises Medicare Advantage (MA or Part C), Medicare Prescription Drug Benefit (Part D), Medicare Cost Plan, and Programs of All-Inclusive Care for the Elderly (PACE) regulations to implement changes related to Star ratings, marketing and communications, health equity, provider directories, coverage criteria, prior authorization, network adequacy, and other programmatic areas. The new rule also promotes health equity and implements a key provision of the Inflation Reduction Act to lower prescription drug costs.
“The Biden-Harris Administration has made exceptionally clear that one of its top priorities is protecting and strengthening Medicare,” said CMS Administrator Chiquita Brooks-LaSure in the announcement. “With this final rule, CMS is putting in place new safeguards that make it easier for people with Medicare to access the benefits and services they are entitled to, while also strengthening the Medicare Advantage and Part D programs.”
Here is summary of the key changes:
Curtails misleading marketing practices
To protect seniors from confusing and potentially misleading marketing practices when exploring MA and Part D coverage, CMS prohibits ads that do not mention a specific plan name, or if they use the Medicare name, CMS logo, and products or information issued by the federal government, including the Medicare care, in a misleading the way. The change is due to the proliferation of certain television advertisements that generically promote enrollment in MA plans and may confuse beneficiaries.
The final rule also strengthens accountability for plans to monitor agent and broker activity and finalizes requirements to further protect beneficiaries by ensuring they receive accurate information about Medicare coverage and are aware of how to access accurate information from other available sources.
CMS noted in a fact sheet that it is finalizing 21 of the 22 provisions it proposed in December. Seventeen of the 21 provisions are finalized as the agency proposed. Four provisions will be finalized but with modifications:
- Permits agents to make business reply cards available at educational events
- Requires agents to tell prospective enrollees how many plans are available from the organization for whom they sell
- Extends the length of time agents are able to recontact beneficiaries to discuss plan options to 12 months
- Allows an agent to meet with a beneficiary without waiting the full 48-hour cooling off period when the timeframe runs up against the end of an election period, or a beneficiary faces transportation or access challenges, or the beneficiary voluntarily walks into an agent’s office
CMS said it will continue to explore the provision that is not being finalized in this rule in possible future rulemaking.
Removes barriers to care created by complex prior authorization and utilization management
The final rule streamlines prior authorization requirements and reduces disruption for enrollees by requiring that a granted prior authorization approval remains valid for as long as medically necessary to avoid disruptions in care. It requires MA plans to annually review utilization management policies and ensure that health care professionals with relevant expertise review denials of coverage based on medical necessity before MA plans issue denials.
These policies complement proposals in CMS’ Advancing Interoperability and Improving Prior Authorization Processes Proposed Rule.
RELATED: CMS proposes rule to overhaul the prior authorization process: 5 things to know
CMS said it is putting in place important protections regarding utilization management policies and coverage criteria that ensure MA enrollees receive the same access to medically necessary care that they would receive in traditional Medicare. This change aligns with recent Office of Inspector General (OIG) recommendations. Specifically, CMS clarifies rules related to acceptable coverage criteria for basic benefits by requiring that MA plans comply with national coverage determinations (NCD), local coverage determinations (LCD), and general coverage and benefit conditions included in traditional Medicare regulations.
When coverage criteria are not fully established, the final rule also allows MA organizations to create internal coverage criteria based on current evidence in widely used treatment guidelines or clinical literature made publicly available to CMS, enrollees, and providers. CMS also more clearly defines when applicable Medicare coverage criteria are not fully established by explicitly stating the circumstances under which MA plans may apply interval coverage criteria when making medical necessity decisions. The agency said that permitting the use of publicly accessible internal coverage criteria in limited circumstances is necessary to promote transparent and evidence-based clinical decisions by MA plans that are consistent with traditional Medicare.
In addition, the final rule streamlines prior authorization requirements, including adding continuity of care requirements and reducing disruptions for beneficiaries. CMS requires that coordinated care plan prior authorization 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. It also requires that coordinated care plans 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 authorization for an active court of treatment.
To ensure prior authorization is used appropriately, CMS requires all MA plans to establish a utilization management committee to review policies annually and ensure consistency with traditionally Medicare’s national and local coverage decisions and guidelines.
To address concerns that the proposed rule didn’t sufficiently define the expected duration of “course of treatment,” the final rule requires that 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 in accordance with applicable coverage criteria, the patient’s medical history, and the treating provider’s recommendation.
In the fact sheet, CMS said that these changes will help ensure enrollees have consistent access to medically-necessary care while also maintaining medical management tools that emphasize the important role MA plans play in coordinating medically-necessary care.
Expands access to behavioral health care
The final rule strengthens behavioral health network adequacy in MA by adding clinical psychologists and licensed clinical social workers to the list of evaluated specialties. These specialty types will also be eligible for the 10-percentage point telehealth credit. CMS is also finalizing wait time standards for behavioral health and primary care services and more specific notice requirements from plans to patients when these providers are dropped from their networks. In addition, CMS will require most types of MA plans to include behavioral health services in care coordination programs, ensuring that behavioral health care is a core part of person-centered care planning.
Other changes in the final rule will:
- Amend general access to services standards to include explicitly behavioral health services
- Codify standards for appointment wait times for primary care and behavioral health services
- Clarify that emergency behavioral health services must not be subject to prior authorization
- Require that MA organizations must notify enrollees when their behavioral health or primary care providers are dropped midyear from networks
- Require MA organizations to establish care coordination programs, including coordination of community, social, and behavioral health services to help move toward parity between behavioral health and physical health services and advance whole-person care
Makes enhancements to Star ratings
CMS finalizes new methodological enhancements to the Star ratings program to further drive quality improvement. The changes include a health equity index reward beginning with the 2027 Star ratings that will reward MA and Medicare Part D plans that provide excellent care for underserved populations. Plans will be required to provide culturally competent care to an expanded list of populations and to improve equitable access to care for those with limited English proficiency through newly expanded requirements for providing materials in alternate formats and languages. CMS also reduces the weight of patient experience/complaints and access measures to further align with other CMS quality programs and the current CMS Quality Strategy. In addition, CMS also includes an additional rule for the removal of Star ratings measures and removes the 60 percent rule that is part of the adjustment for extreme and uncontrollable circumstances.
The agency said the final rule balances patient experience/compliant measures, access measures, and health outcomes measures in the Star rating program to more effectively focus both on patient-centric care and on improving clinical outcomes.
Advances health equity
CMS said it is committed to advancing health equity for all, including those who have been historically underserved, marginalized, and adversely affected by persisted poverty and inequality. The agency is clarifying current rules, expanding the example list of populations that MA organizations must provide services in a culturally competent manner, including:
- People with limited English proficiency or reading skills
- People of ethnic, cultural, racial, or religious minorities
- People with disabilities
- People who identify as lesbian, gay, bisexual, or other diverse sexual orientations
- People who identify as transgender, nonbinary, and other diverse gender identifies, or people who were born intersex
- People who live in rural areas and other areas with high levels of deprivation
- People who otherwise are adversely affected by persistent poverty or inequality
CMS noted that research demonstrates low digital health literacy, especially among populations experiencing health disparities, continues to impede telehealth access and worsen care gaps particularly among older adults. The final rule requires MA plans to develop and maintain procedures to offer digital health education to enrollees to improve access to medically necessary covered telehealth benefits. CMS is also enhancing current best practices by requiring MA organizations to include providers’ cultural and linguistic capabilities in provider directors. The agency said this change will improve the quality and usability of provider directories, particularly for non-English speakers, limited English proficient individuals, and enrollees who use American Sign Language. Finally, CMS will require that MA plans’ quality improvement programs include efforts to reduce disparities.
Implements the Inflation Reduction Act’s new prescription drug law
The final rule also implements a key provision of the Inflation Reduction Act that improves access to affordable prescription drug coverage for approximately 300,000 low-income individuals. CMS is expanding eligibility for the full low-income subsidy benefit (also known as “extra help”) to individuals with incomes up to 150 percent of the federal poverty level who meet eligibility criteria. Beginning January 1, 2024, this change will provide the full low-income subsidy to those who would currently qualify for the partial low-income subsidy. As a result of this change, eligible enrollees will have no deductible, no premiums (if enrolled in a “benchmark” plan), and fixed, lowered copayments for certain medications under Medicare Part D.