CMS has finalized its CY 2024 Medicare Advantage final rule, streamlining prior authorization requirements and increasing marketing oversight while attempting to align the program more closely with traditional Medicare.1
Under the rule, coordinated care plans’ prior authorization policies may only confirm medical criteria and/or ensure that a treatment is medically necessary. Denial decisions based on medical necessity will need to be reviewed by health care professionals with relevant expertise before a plan can issue a denial.2
Plans must also ensure that any granted approvals remain valid for as long as medically necessary. If a member currently undergoing treatment switches to a new MA plan, coordinated care plans must provide at least a 90-day transition period during which the new plan cannot require prior authorization for the current treatment course.
Additionally, MA plans must establish a Utilization Management Committee to review their prior authorization policies each year and ensure they are consistent with traditional Medicare.
CMS is also tightening its oversight of marketing, prohibiting ads that do not mention the name of a specific MA plan or that use words and imagery that could be confusing. Advertising must not use language or Medicare logos in ways that could be misleading or misrepresent the plan.
The agency also strengthens plans’ ability to monitor agent and broker activity.
The rule goes on to address dissemination of appropriate information, finalizing requirements that ensure members receive accurate information about coverage and that they know how to access accurate information from other sources.1 It also stipulates that MA plans must develop and maintain procedures for digital health education to improve access to telehealth benefits.
Health equity
The rule establishes a health equity index in the Star Ratings program to reward MA and Medicare Part D plans that provide high-quality care to underserved populations.3
Additionally, MA organizations must include providers’ cultural and linguistic capabilities in provider directories and adhere to expanded requirements for providing materials in additional formats and languages.3,4 Their quality improvement programs must include efforts to reduce disparities, and they must provide culturally competent care to a broader list of populations, including people:
- With limited English proficiency or reading skills
- Of ethnic, cultural, racial or religious minorities
- With disabilities
- Who identify as lesbian, gay, bisexual or other diverse sexual orientations
- Who identify as transgender, nonbinary and other diverse gender identities, or people who were born intersex
- Who live in rural areas and other areas with high levels of deprivation
- Who are otherwise adversely affected by persistent poverty or inequality.
The agency also aims to address behavioral health by adding clinical psychologists and licensed clinical social workers to the list of specialty types for which there are network standards. CMS is also further finalizing wait time standards for behavioral health and primary care services.3
Finally, the rule implements provisions of the Inflation Reduction Act to improve access to affordable prescription drugs, expanding eligibility for the full low-income subsidy benefit to people with incomes up to 150% of the federal poverty level who meet eligibility criteria.2 Eligible beneficiaries will have no deductible, no premiums and fixed, lowered copayments for certain medications under Medicare Part D.
Plans that familiarize themselves with the final rule and its requirements and prepare early will see a smoother transition in their prior authorization policies. They will also be able to provide more consistent, equitable care to a wider swath of their membership, helping to close gaps and ensure more people receive the best care possible.
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References
- 2024 Medicare Advantage and Part D Final Rule (CMS-4201-F). CMS. April 5, 2023. https://www.cms.gov/newsroom/fact-sheets/2024-medicare-advantage-and-part-d-final-rule-cms-4201-f
- HHS Finalizes Rule to Strengthen Medicare, Improve Access to Affordable Prescription Drug Coverage, and Hold Private Insurance Companies Accountable to Delivering Quality Health Care for America’s Seniors and People with Disabilities. CMS. April 5, 2023. https://www.cms.gov/newsroom/press-releases/hhs-finalizes-rule-strengthen-medicare-improve-access-affordable-prescription-drug-coverage-and-hold
- Lagasse, J. CMS final rule aims to strengthen Medicare, drug affordability. Healthcare Finance News. April 6, 2023. https://www.healthcarefinancenews.com/news/cms-final-rule-aims-strengthen-medicare-drug-affordability
- Bailey, V. Medicare Advantage Final Rule Addresses Prior Authorization, Health Equity. HealthPayerIntelligence. April 5, 2023. https://healthpayerintelligence.com/news/medicare-advantage-final-rule-addresses-prior-authorization-health-equity
