The Centers for Medicare and Medicaid Services (CMS) published Final Rule 4201-F (88 FR 22120) on April 12 revising the Medicare Advantage (Part C), Medicare Prescription Drug Benefit (Part D), Medicare cost plan, and Programs of All-Inclusive Care for the Elderly (PACE) regulations to implement changes related to Star Ratings, marketing and communications, health equity, provider directories, coverage criteria, prior authorization, passive enrollment, network adequacy, and other programmatic areas.
The following are some of the most significant changes MA plans and Dual eligible Special Needs Plans (D-SNP) should pay close attention to.
Strategy to Advance Health Equity
Just as last year’s rule did, this CY24 Rule continues the trend of the Biden Administration to advance health equity and implement the Inflation Reduction Act. CMS is lowering prescription drug costs in the name of improving access to affordable prescription drug coverage for low-income individuals. CMS also finalized changes to the Star Ratings program, including a health equity index reward to incentivize plans to improve care for beneficiaries with certain social risk factors.
Coverage Criteria
CMS clarified clinical criteria guidelines to ensure people with MA receive access to the same care as Traditional Medicare. CMS is requiring plans to comply with NCDs, LCDs, and FFS general coverage and benefit conditions, and are allowing plans to create criteria when existing coverage criteria are not fully established.
Cultural Competency
CMS added several populations that MA plans must now serve in culturally competent ways, including:
Those with Limited English Proficiency or reading skills.
Those who are considered ethnic, cultural, racial, or religious minorities.
Those living with disabilities.
Those who identify as lesbian, gay, bisexual, or other diverse sexual orientations.
Those who identify as transgender, nonbinary, and other diverse gender identities, or people who were born intersex.
Those who live in rural areas and other high levels of deprivation and who are otherwise adversely affected by persistent poverty or inequality.
Prior Authorization
Prior authorization approvals must now remain valid for as long as medically necessary to avoid disruptions in care. Plans will need to annually review their UM policies and require medical necessity denials be reviewed before denials can be issued. Plans must also provide 90-day transition periods when beneficiaries switch to new MA plans. This rule echoes proposals issued by CMS in their December 2022 ‘Advancing Interoperability and Improving Prior Authorization Processes’ proposed rule (0057-P).
Misleading Marketing
Medicare advertising that does not mention specific plan names, or uses words that may confuse, or mislead beneficiaries, or misrepresent a plan are prohibited in the new final rule. Agents are allowed to make Business Reply Cards available at educational events and they must tell prospective enrollees how many plans are available from the organizations for whom they sell. Agent may also meet with beneficiaries without waiting for the 48-hour cooling off period if the beneficiary is near the end of their election period. Significantly, plans must also now have an oversight plan to monitor marketing activity and report non-compliance to CMS.
Our distinguished team of experts collaborated to provide an in-depth analysis of the 226-page final regulation. Email us directly if you would like a copy of our analysis.
Unsure where to start? Our team has outlined a strategic path based on the final rule and what health plans should be thinking and planning for 2024 and beyond. Contact us today to get started.