Medicare Advantage/Part D Final Rule

Early in April, CMS released the 2024 Medicare Advantage/Part D Final Rule and within, there are a number of interesting policy shifts that could benefit providers. The rule addresses a common practice that has been frankly, often abused by Med Advantage plans – prior authorizations or more commonly known as, “prior auths”. The crux is authorization provisions created delays in care and sometimes, denials for services that the patient and/or his/her physician believes are medically necessary. The SNF industry has most often been on the denial side of prior authorization requirements, either for the whole stay (initial transfer) or for a requested longer stay. The fact sheet for the final rule is here: https://www.cms.gov/newsroom/fact-sheets/2024-medicare-advantage-and-part-d-final-rule-cms-4201-f

With respect to prior authorizations, the rule seeks to make their use more connected to national coverage determinations (NCDs) and local coverage determinations (LCD), common to traditional Medicare. Back in April of 2022, the HHS Inspector General issued a report that included findings of Med Advantage plans use of authorization provisions to issue fairly widespread denials for various care and services. The denials either bar access to care for the patient or in some cases, deny payment to the provider for care and services rendered, subsequently determined by the Med Advantage plan to be “not medically necessary”.

The study noted that the Med Advantage plans were using medical criteria more restrictive than criteria under traditional Medicare (the national or local coverage determinations). Among cases reviewed, 13% of the Med Advantage denials were for care or services that would be covered under traditional Medicare. Other denials were technical in nature whereby the Med Advantage plan denied an authorization as insufficient in documentation yet, the patient medical record contained sufficient documentation of the medical need. In the cases of payment denials, while the payment requests were proper in terms of meeting Medicare criteria, the denials that did occur were due to processing or human claim review error. At a rate of 18%, this is a bit alarming as Medicare fee-for-service claims, properly billed, don’t have such an error rate. The OIG report is here: https://oig.hhs.gov/oei/reports/OEI-09-18-00260.asp

Another target within the rule with respect to Medicare Advantage plans has to do with marketing practices. The plans have become popular such that today, 45 % of all Medicare beneficiaries are enrolled in Med Advantage plans. Medicare anticipates this number to rise to 50% by 2025. Apparently, those annoying generic television ads promoting various Medicare Advantage plan features, some featuring celebrities like JJ Walker and Joe Namath, have gotten notice in Washington. No longer will that style of ad be permitted instead, requiring a specific plan to be identified and each ad, to eliminate images and language that is confusing or misleading (not sure how that will be monitored).

Another change or improvement relates to behavioral health access and coverage criteria. CMS is finalizing a new set of rules requiring Medicare Advantage plans to: “(1) add Clinical Psychologists and Licensed Clinical Social Workers as specialty types for which we set network standards, and make these types eligible for the 10-percentage point telehealth credit; (2) amend general access to services standards to include explicitly behavioral health services; (3) codify standards for appointment wait times for primary care and behavioral health services; (4) clarify that emergency behavioral health services must not be subject to prior authorization; (5) require that MA organizations notify enrollees when the enrollee’s behavioral health or primary care provider(s) are dropped midyear from networks; and (6) require MA organizations to establish care coordination programs, including coordination of community, social, and behavioral health services to help move towards parity between behavioral health and physical health services and advance whole-person care.”

I’m encouraging providers to read the rule’s fact sheet. Medicare Advantage providers will not simply or quickly, make wholesale adjustments to their existing practices because of this rule. Additionally, providers should always be aware of National and Local Coverage Determinations and use the same, as a “road map” for dealing with Med Advantage coverage and authorization issues. Providers will need to push the plans to make proper adjustments accordingly and to protect and advocate, for their patients. It will take time for the Med Advantage industry to adjust but, movement will happen quicker if providers hold the plans accountable.