Courtesy of the National Association for Home Care & Hospice

On April 5, 2023, the Centers for Medicare & Medicaid Services (CMS) issued a final rule, Contract Year 2024 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicare Cost Plan Program, and Programs of All-Inclusive Care for the Elderly, that implements several provisions from a December 27, 2022, proposed rule aimed at protecting beneficiaries enrolled in Medicare Advantage (MA) plans. CMS intends to address all of the remaining proposals from the proposed rule in subsequent rulemaking.

Provisions most important for home health providers relate to acceptable coverage criteria, prior authorization, utilization management,  behavioral health, marketing, and health equity.

Coverage Criteria

• Requires 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.
• When coverage criteria are not fully established, permits MA organizations to create internal coverage criteria based on current evidence in widely used treatment guidelines or clinical literature made publicly available to CMS, enrollees, and providers.

Prior Authorization and Utilization Management

• Limits the use of prior authorization processes only to confirm the presence of diagnoses or other medical criteria that are the basis for coverage determinations for the specific item or service
• Requires that a granted prior authorization approval remains valid for as long as medically necessary.
• Requires MA plans to establish utilization management committees to review all utilization management, including prior authorization, policies annually and ensure they are consistent with the coverage requirements.
• Requires that denials of coverage be based on medical necessity be reviewed by health care professionals with relevant expertise before a denial can be issued.

Commenters expressed concerns over the proposal to remove the existing flexibility of MA plans to provide the same level of care in different settings. One commenter stated that removing the flexibility for plans to provide care in alternate settings could shift care from beneficiary homes to institutional settings, resulting in increased costs for both the plans and beneficiaries.

CMS responded that an MA plan may make its enrollees aware of other covered treatment options or encourage specific treatment options as part of the MA plan’s coordination and management of care for enrollees.

Behavioral Health  

• Adds clinical psychology and licensed clinical social work as specialty types that will be evaluated as part of the network adequacy.
• Finalizes wait time standards for behavioral health and primary care services and more specific notice requirements from plans to patients when these providers are dropped from their networks.

Marketing

• Requires notification to enrollees annually, in writing, of the ability to opt out of phone calls regarding MA and Part D plan business.
• Requires agents to explain the effect of an enrollee’s enrollment choice on their current coverage whenever the enrollee makes an enrollment decision.
• Simplifies plan comparisons by requiring medical benefits to be in a specific order and listed at the top of a plan’s summary of benefits.
• Limits the time that a sales agent can call a potential enrollee to no more than 12 months following the date that the enrollee first asked for information.
• Limits the requirement to record calls between third-party marketing organizations (TPMOs) and beneficiaries to marketing (sales) and enrollment calls.
• Prohibits a marketing event from occurring within 12 hours of an educational event at the same location.
• Clarify that the prohibition on door-to-door contact without a prior appointment still applies after collecting a business reply card or the scope of an appointment card.
• Prohibits marketing of benefits in a service area where those benefits are not available,
• Prohibits advertisements if they do not mention a specific plan name.
• Prohibits the use of the Medicare name, CMS logo, and products or information issued by the Federal Government, including the Medicare card in advertisements, misleadingly.
• Strengthens accountability for plans to monitor agent and broker activity.
• Prohibits advertising inaccurate cost savings.

Health Equity

• Establishes a health equity index in the Star Ratings program that will reward Medicare Advantage and Medicare Part D plans that provide excellent care for underserved populations.