CMS Calls a Time Out New Rules For Medicare Advantage Plans

 

CMS Blows The Whistle 

The Centers for Medicare & Medicaid Services (CMS) finalized several new rules for Medicare Advantage (MA) plans in 2023, effective for 2024 and beyond. These rules aim to improve the quality of care for beneficiaries, increase transparency, and address concerns about cost-shifting. Here's a summary of the key changes:

1. Coverage Protections:

• Prohibition of Denials Based on Internal Criteria: MA plans can no longer deny coverage for Medicare-covered services based on their own internal rules if those rules are stricter than Medicare guidelines. This ensures beneficiaries have access to the same services regardless of their plan.
• Two-Midnight Rule: MA plans must adhere to the "Two-Midnight Rule" for inpatient admissions. This means a patient generally needs to be admitted for at least two midnights to be considered an inpatient stay, which affects coverage and billing.

2. Health Equity Measures:

• Health Equity Index (HEI): CMS is replacing its current reward factor for high Star Ratings with a new HEI reward, starting in 2024. This index will incentivize plans to improve performance for patients with certain social risk factors, promoting health equity.

3. Transparency and Star Ratings:

• Reduced Weight on Patient Experience Measures: The weight of patient experience and complaint measures in Star Ratings will be reduced, as these measures have been criticized for being unreliable and potentially biased.
• Removal of Certain Star Ratings: Some Star Ratings categories are being removed or adjusted, aiming to streamline the system and focus on more meaningful measures.

4. Additional Changes:

• Clarification on Prior Authorization: CMS issued new guidance on prior authorization processes, aiming to make them more transparent and efficient for beneficiaries.
• Focus on Social Determinants of Health: CMS encourages MA plans to address social determinants of health, such as housing and food insecurity, which can impact beneficiaries' health outcomes.

To learn more you may visit [https://www.cms.gov/newsroom/fact-sheets/2024-medicare-advantage-and-part-d-final-rule-cms-4201-f] or Click Here and a licensed agent will be in contact.