Medicare Compliance & Reimbursement

Access, transparency, and communication play key roles in policymaking.

COVID revealed a cornucopia of care disparities in federal healthcare programs, from delays in authorization for treatment to marketing scams to basic access to care. In its latest proposals, Medicare shines the spotlight on managed care programs, addressing these issues and other areas of concern. Read on for the details.

Context: On Dec. 27, 2022, the Centers for Medicare & Medicaid Services (CMS) published its Medicare Advantage (MA) and Part D proposed rule for the 2024 contract year in the Federal Register. CMS focuses on beneficiary protections, behavioral health, and equity in its proposals as well as implementing an Inflation Reduction Act provision.

“We are taking feedback from thousands of Americans and turning it into concrete action to strengthen Medicare for the millions of Americans who rely on it,” notes HHS Secretary Xavier Becerra in a release on the proposed rule. “From streamlining prior authorization to cracking down on misleading marketing, we are committed to ensuring that everyone can have peace of mind and get the health care they need.”

The proposed rule “takes important steps to hold Medicare Advantage plans accountable for providing high quality coverage and care to enrollees,” says CMS Administrator Chiquita Brooks-LaSure. Additionally, “the rule also strengthens Medicare prescription drug coverage and implements an important provision of the Inflation Reduction Act to help more people with Medicare who have modest incomes afford their prescriptions,” she adds.

Consider These Key Points

CMS aims to safeguard MA and Part D beneficiaries in its proposed rule for contract year 2024. From revising prior authorization policies to setting stronger marketing guidelines to aligning with the Behavioral Health Strategy initiative, CMS hopes to cut costs and bolster access to care.

Here’s a breakdown of the five biggest proposals on the table:

Highlights among the proposed Star Ratings changes include: reducing the patient experience/complaint measure weight from 4 to 2; revising or removing certain MA and Part D measures; updating measures’ methodology; and eliminating the 60 percent rule for extreme and uncontrollable circumstances (EUC) adjustments.

2. Know these prior authorization modifications. Since the HHS Office of Inspector General (OIG) released a report last April, MA plans’ snafus with prior authorization have been on the feds’ radar (see Medicare Compliance & Reimbursement, Vol. 48, No. 11). CMS proposes a plethora of prior authorization provisions to address the problems.

First, MA plans would “develop and use coverage criteria and utilization management policies to ensure Medicare Advantage enrollees receive the same access to medically necessary care they would receive in Traditional Medicare,” according to a fact sheet on the proposed rule. CMS wants to do this by “streamlining prior authorization requirements” to make it easier for MA plan patients to receive care without disruption through the “full course of treatment,” the agency says.

CMS also proposes that MA plan coverage decisions be made and “reviewed by professionals with relevant expertise.”

Reminder: CMS released the Advancing Interoperability and Improving Prior Authorization Processes proposed rule in December 2022, which was a followup to a 2020 rule (see`Medicare Compliance & Reimbursement, Vol. 48, No. 24). These latest proposals are “complementary” to the previous rules, the agency indicates.