CMS has proposed a rule that would prioritize health equity, improve mental health care access, expand prescription drug coverage and streamline prior authorization for Medicare Advantage plans.
Under the rule, the agency would include a health equity index in the star ratings program to incentivize high-quality care for underserved populations.1 The index would apply beginning in 2027, and it would include data from the 2024 and 2025 measurement periods.2
Plans would need to provide culturally competent care to additional populations and improve access for people with limited English proficiency under new interpreter standards and by providing materials in alternate formats and languages.1
The agency would also reduce the weight of patient experience/complaints and access measures by half, from four to two, “to further align efforts with other CMS quality programs and the current CMS Quality Strategy.”1,3
The net impact of all proposed provisions affecting the Star ratings program would be $24.97 billion in savings over 10 years, according to the rule.
Mental health care access
A key part of the proposal is strengthening behavioral health care by adding clinical psychologists, licensed clinical social workers and prescribers of opioid use disorder treatments to the list of evaluated specialties. It would set new minimum wait time standards for behavioral health and primary care services and require most types of MA plans to include behavioral health service in care coordination programs. Plans would be subject to more specific requirements for providing notice to members when primary care and behavioral health providers are dropped from the network.1
Prior authorization updates
Prior authorization requirements would be updated under the proposed rule, with the addition of continuity of care provisions requiring prior authorization to remain valid for the full course of a member’s treatment. Plans would need to provide a minimum 90-day transition period when an enrollee currently undergoing treatment switches to a new MA plan.
Additionally, plans would be required to appoint a Utilization Management Committee to review prior authorization policies on an annual basis to assure they align with Traditional Medicare.4
If there is no applicable Medicare statute, regulation, National Coverage Determination or Local Coverage Determination for a particular item or service, MA plans must include “current evidence in widely used treatment guidelines or clinical literature made publicly available to CMS, enrollees and providers when creating internal clinical coverage criteria,” CMS says.4
CMS is seeking feedback from MA plans and industry stakeholders on the proposed rule, with comments due by Feb. 13.
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- HHS Proposes Rule to Strengthen Beneficiary Protections, Improve Access to Behavioral Health Care, and Promote Equity for Millions of Americans with Medicare Advantage and Medicare Part D. CMS. Dec 14, 2022. https://www.cms.gov/newsroom/press-releases/hhs-proposes-rule-strengthen-beneficiary-protections-improve-access-behavioral-health-care-and
- Medicare Program: Contract Year 2024 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicare Cost Plan Program, etc. Federal Register. Dec. 14, 2022. https://www.federalregister.gov/public-inspection/2022-26956/medicare-program-contract-year-2024-policy-and-technical-changes-to-the-medicare-advantage-program.
- Emerson, J. CMS proposes rule to further overhaul Medicare Advantage marketing, prior authorization. Becker’s Payer Issues. Dec. 15, 2022. https://www.beckerspayer.com/policy-updates/cms-proposes-rule-to-further-overhaul-medicare-advantage-marketing-prior-authorization.html
- Contract Year 2024 Policy and Technical Changes to the Medicare Advantage and Medicare Prescription Drug Benefit Programs Proposed Rule (CMS-4201-P). CMS Newsroom. Dec. 14, 2022. https://www.cms.gov/newsroom/fact-sheets/contract-year-2024-policy-and-technical-changes-medicare-advantage-and-medicare-prescription-drug