April 7, 2023
CMS Releases 2024 Policy and Technical Changes to MA and Part D Final Rule
On April 5, the Centers for Medicare & Medicaid Services (CMS) issued the Medicare Advantage (MA) and Part D Final Rule for Contract Year 2024, which includes several notable changes to utilization management requirements. The Network previously submitted comments in response to the proposed rule and applauded CMS for recognizing the barriers to timely access to care created by the increased use of prior authorization by MA plans.
CMS is finalizing the following proposals The Network commented on which are aimed at addressing concerns regarding MA plans’ use of prior authorization and its effect on beneficiary access to care:
- CMS is clarifying clinical criteria guidelines to ensure people with MA receive access to the same medically necessary care they would receive in Traditional Medicare.
- CMS is finalizing its proposal to require that MA plans must comply with national coverage determinations (NCD), local coverage determinations (LCD), and general coverage and benefit conditions included in Traditional Medicare regulations. CMS is also finalizing that when coverage criteria are not fully established, MA organizations may create internal coverage criteria based on current evidence in widely used treatment guidelines or clinical literature made publicly available. CMS also explicitly states the circumstances under which MA plans may apply internal coverage criteria when making medical necessity decisions.
- CMS is finalizing its proposal that prior authorization policies for coordinated care plans may only be used to confirm the presence of diagnoses or other medical criteria and/or ensure that an item or service is medically necessary.
- CMS is finalizing its proposal that an approval granted through the prior authorization process must be valid for the duration of the approved prescribed or ordered course of treatment or service. To address concerns that the proposed rule did not sufficiently define the expected duration of “course of treatment,” the final rule requires that approval of a prior authorization request for a course of treatment must be valid for “as long as medically reasonable and necessary to avoid disruptions in care in accordance with applicable coverage criteria, the patient’s medical history, and the treating provider’s recommendation.”
- CMS is also finalizing its proposal to require coordinated care plans to provide a minimum 90-day transition period when an enrollee currently undergoing treatment switches to a new MA plan, switches from Traditional Medicare to an MA plan, or is new to Medicare, during which the new MA plan may not require prior authorization for the active course of treatment.
- Finally, CMS is finalizing its proposal to require all MA plans to establish a Utilization Management Committee, led by a plan’s Medical Director, to review policies annually and ensure consistency with Traditional Medicare’s national and local coverage decisions and guidelines.
To view the press release from CMS, CLICK HERE.
To view the fact sheet from CMS, CLICK HERE.
To read the full text of the final rule, CLICK HERE.
To read The Network’s comments on the proposed rule, CLICK HERE.