CMS final rule aims to strengthen Medicare, drug affordability

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In a bid to put protections in place for Medicare Advantage, the Department of Health and Human Services, through the Centers for Medicare and Medicaid Services, is finalizing a rule it said would strengthen MA and hold health insurance companies to higher standards.

Specifically, the 2024 Medicare Advantage and Part D Final Rule looks to crack down on misleading marketing schemes by Medicare Advantage plans, Part D plans and their downstream entities; remove barriers to care created by complex coverage criteria and utilization management; and expand access to behavioral healthcare, CMS said.

The new rule will also promote health equity, HHS said, and implement a key provision of the Inflation Reduction Act meant to improve access to affordable prescription drug coverage for an estimated 300,000 low-income individuals.

CMS said it had received numerous inquiries regarding the use of prior authorization by Medicare Advantage plans and the effect on beneficiary access to care. In the rule, CMS addressed prior authorization by requiring approvals to be valid as long as medically necessary. 

WHAT'S THE IMPACT?

The final rule includes changes intended to protect people exploring Medicare Advantage and Part D coverage from confusing and potentially misleading marketing practices. Ads will be prohibited if they 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 card – in a misleading way. The final rule also strengthens accountability for plans to monitor agent and broker activity.

CMS said it's also providing 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. 

The 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 – requiring Medicare Advantage plans to annually review utilization management policies, and requiring denials of coverage based on medical necessity be reviewed by healthcare professionals with relevant expertise before a denial can be issued.

When it comes to behavioral health, CMS said it's strengthening behavioral health network adequacy in Medicare Advantage by adding clinical psychologists and licensed clinical social workers to the list of evaluated specialties. 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.

CMS said it's also establishing a health equity index in the Star Ratings program that will reward Medicare Advantage and Medicare Part D plans that provide excellent care for underserved populations. Plans will also 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.

And as outlined in President Biden's new prescription drug law, CMS is expanding eligibility for the full low-income subsidy benefit – also known as "Extra Help" – to individuals with incomes up to 150% 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, HHS said.

REACTION

MGMA SVP of Government Affairs Anders Gilberg said, "MGMA supports today's action by CMS to finalize its proposals to reign in detrimental prior authorization practices, thereby strengthening the Medicare Advantage (MA) program. We are thankful that the agency heeded our call to finalize the continuity of care provision, limiting dangerous disruptions and delays to necessary patient care. By finalizing its proposal to require MA plans to form Utilization Management Committees, CMS will provide greater consistency across MA and Traditional Medicare's coverage decisions and guidelines. This rule is a step in the right direction to adequately address prior authorization reform."

Ashley Thompson, senior vice president, Public Policy Analysis and Development at the American Hospital Association, said, "The AHA commends CMS for finalizing critical policies that will help ensure beneficiaries enrolled in Medicare Advantage have access to the medically necessary healthcare services to which they are entitled. In addition, we appreciate the agency's increased attention to oversight of Medicare Advantage plans. Hospitals and health systems have raised the alarm that beneficiaries enrolled in some Medicare Advantage plans are routinely experiencing inappropriate delays and denials for coverage of medically necessary care. This rule will go a long way in protecting patients and ensuring timely access to care, as well as reducing inappropriate administrative burden on an already strained healthcare workforce."

Thompson also commended provisions to ensure more consistency between Medicare Advantage and traditional Medicare by CMS curtailing what she called overly restrictive coverage policies that impede access to care and add cost and burden and for addressing access gaps in behavioral health and post-acute care services.

Mary Beth Donahue, president and CEO of Better Medicare Alliance said, "CMS' final policy rule for 2024 will support Medicare Advantage's efforts in bridging the health equity gap and providing high-quality care. Further, we support provisions to streamline the prior authorization process to ensure timely access to care as well as steps to ensure transparency and accountability within Medicare Advantage."

THE LARGER TREND

The administration has undertaken a series of actions on the Medicare Advantage front. 

In February, CMS finalized a rule to start recovering improper payments made to Medicare Advantage plans through audits for the first time since 2007. Recovering these improper payments and returning this money to the Medicare Trust Funds, CMS said, will protect the fiscal sustainability of Medicare and allow the program to better serve seniors and people with disabilities.

Last week, CMS finalized policies in the 2024 Medicare Advantage and Part D Rate Announcement to improve payment accuracy and ensure taxpayer dollars are appropriately safeguarded.

Twitter: @JELagasse
Email the writer: Jeff.Lagasse@himssmedia.com