In April, the Centers for Medicare & Medicaid Services (CMS) issued a Final Rule regarding the Medicare Advantage (MA) and Part D programs. The Final Rule includes changes related to various aspects of those programs, including utilization management (UM) programs, Star Ratings, marketing and communications, health equity, provider directories, and network adequacy.
Major Changes
Some of the biggest changes in the final rule are related to prior authorization and continuity of care requirements for MA coordinated care plans. The Final Rule amends the MA regulations to require that the prior authorization policies of MA 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 (or clinically appropriate in the case of certain supplemental benefits). CMS emphasized that prior authorization should not function to delay or discourage care.
The Final Rule further requires that when an MA coordinated care plan approves a prior authorization request for a course of treatment, the approval must be valid for as long as medically necessary to avoid disruptions in care in accordance with applicable coverage criteria, the patient’s medical history, and the treating provider’s recommendation. The Final Rule also establishes continuity of care requirements for beneficiaries currently undergoing treatment who switch to a different MA coordinated care plan or newly enroll in an MA coordinated care plan. In particular, during the initial 90 days of such enrollee’s enrollment in the MA plan, the plan may not require prior authorization for the active course of treatment, even when the treatment is being provided by a nonparticipating provider.
Furthermore, following scrutiny by the Senate Finance Committee and increasing oversight of marketing activity during last year’s annual enrollment period, CMS proposed extensive changes to Medicare marketing. The Final Rule includes limits on how marketing may use the Medicare name, logo, and card; prohibitions on advertising benefits that are not available in the service area; and requires at least annual notification to beneficiaries that they can opt-out of being contacted to discuss plan business. The Final Rule also prohibits collecting a scope of appointment (SOA) at educational events.
The Final Rule also requires waiting periods for certain marketing activities, such as 12 hours between an educational event and a marketing event in the same place and 48 hours between an SOA and a personal marketing appointment. Notably, however, CMS adopted 2 exceptions to the 48-hour requirement in response to comments: (1) it does not apply to appointments within 4 days of the end of an election period; and (2) it does not apply to “an unscheduled in-person meeting initiated by a beneficiary.”
Additionally, consistent with the Biden Administration’s focus on racial equity, the Final Rule broadens the scope of populations considered when evaluating whether services are provided in a culturally competent manner to include, categories such as disabled people, LGBTQIA+ people, and rural people. The Final Rule also updates Medicare Advantage’s provider directory requirements to align them with Medicaid managed care standards for disclosure of provider’s cultural and linguistic capabilities, including languages such as American Sign Language. Provider directories also must include whether a provider offers medications for opioid use disorder. MA plans also must develop processes to offer digital health education to enrollees to facilitate and improve access to telehealth benefits.
Finally, the Final Rule adds two behavioral health provider types—clinical psychology and clinical social work—to network adequacy requirements, along with time and distance and minimum ratio criteria. MAOs can receive a 10-percentage point credit toward the percentage of beneficiaries who reside within the time-and-distance requirements if the plan has one or more clinical psychology or clinical social work providers that provide telehealth benefits. The same timeliness of access to care criteria now apply to behavioral health as medical/surgical care: immediately for urgently needed services or emergencies; within 7 business days for non-emergency or urgent care when the enrollee needs medical attention; and within 30 business days for routine and preventive care. The Final Rule also adds behavioral health services to the conditions for which MA coordinated care plans must coordinate care with community and social services.