Hospitals want CMS to correct MA plan policies on coverage

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The American Hospital Association is asking the Centers for Medicare and Medicaid Services to crack down on Medicare Advantage insurers it says are blatantly flaunting CMS coverage rules.

"We expressed concerns about reports we have received from our members that certain MAOs have indicated they do not intend to make changes to their utilization management programs in response to the new rule. In other cases, it appears some plans are making changes to the terminology they use in denial letters that may be intended to circumvent recent CMS rulemaking," said Ashley Thompson, AHA senior vice president, Public Policy Analysis and Development, in the letter to CMS Deputy Administrator and Director Dr. Meena Seshamani.

One plan recently issued guidance to its network providers indicating that they plan to continue using internal criteria beyond the Traditional Medicare criteria to evaluate inpatient admissions, the letter said. 

"We believe this circumvents CMS' rules regarding the use of more restrictive coverage criteria and the requirement that plans adhere to certain public accessibility and evidentiary standards," Thompson said. "Similarly, we understand from our members that at least one other large, national MAO has reported they will continue to use MCG criteria to evaluate inpatient admissions."

Another plan has issued a policy that adopts a more stringent standard than CMS for evaluating a physician's judgment at the time of admission on whether the care was expected to extend over two midnights, the AHA said.

WHY THIS MATTERS 

"We are deeply concerned that these practices will result in the maintenance of the status quo where MAOs apply their own coverage criteria that is more restrictive than Traditional Medicare proliferating the very behavior that CMS sought to address in the final rule, resulting in inappropriate denials of medically necessary care and disparities in coverage between beneficiaries in MA and those in the Traditional Medicare program," Thompson said.

The AHA wants CMS to issue clarifications on coverage and to make it clear that the flexibility for MA plans to supplement traditional Medicare rules with additional internal coverage criteria is not applicable for medical necessity reviews of inpatient admissions and level of care decisions and should only be used in certain limited circumstances.

The AHA represents nearly 5,000 member hospitals, health systems and other healthcare organizations.

THE LARGER TREND

The 2024 MA final rule ensures better alignment and coverage parity between traditional Medicare and MA, and increases oversight of Medicare Advantage Organizations (MAOs).

Its aim is to strengthen MA and hold health insurers to higher standards through several components, including removing barriers to care created by complex coverage criteria and utilization management, according to CMS.

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. 

The rule also cracks down on misleading marketing schemes by Medicare Advantage plans, Part D plans and their downstream entities and expands access to behavioral healthcare.

It also establishes a health equity index in the MA star ratings system.

Twitter: @SusanJMorse
Email the writer: SMorse@himss.org