Medicare Advantage Regulations Impose Limits on Utilization Management
Key provisions of the Medicare Advantage (MA) calendar year 2024 policy and technical rule take effect on Jan. 1, 2024, limiting the flexibility of MA plans to impose prior authorization requirements and make coverage determinations. As previously reported by LeadingAge National and LeadingAge NY, the new regulations include provisions that:
- Codify and clarify the clinical criteria to be used in utilization management to ensure that MA plans are no more restrictive than Traditional Medicare in their coverage decisions. Specifically, 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, MA organizations may create internal coverage criteria based on widely used treatment guidelines or clinical literature made publicly available to the Centers for Medicare and Medicaid Services (CMS), enrollees, and providers. The rule also limits the circumstances in which plans can use algorithms for purposes of utilization management.
- Limit the uses of prior authorization to confirmation of diagnosis and/or medical necessity and ensure that prior authorizations are valid for a “course of treatment,” which means “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.” The course of treatment definition includes skilled nursing facility (SNF) and home health benefits.
- Require physician-ordered sites of service to be honored by plans beginning Jan. 1, 2024.
- Prohibit plans from retroactively denying an approved, medically necessary service.
- Ensure 90-day transitions for beneficiaries in the middle of treatment without requiring prior authorization.
- Require coverage denials to be reviewed by providers with expertise in the requested services.
- Require plans to establish a Utilization Management Committee that annually reviews utilization management policies.
- Impose additional marketing restrictions to protect beneficiaries from deceptive practices.
LeadingAge National is seeking additional clarification from CMS concerning the requirements of the regulation. It is also seeking feedback from members on their experience in the field with MA plans under the new requirements. More information is available here.
Contact: Karen Lipson, klipson@leadingageny.org