LeadingAge National Comments on Proposed Rule Covering Medicare Advantage and PACE

(Feb. 11, 2025) LeadingAge National submitted an extensive comment letter to the Centers for Medicare and Medicaid Services (CMS) on the proposed Calendar Year (CY) 2026 Medicare Advantage (MA), Part D, and Programs of All-Inclusive Care for the Elderly (PACE) policy and technical rule. The 700+-page rule was far-ranging, covering PACE, supplemental benefit flex cards, prior authorizations, artificial intelligence guardrails, dual-eligible integration policies, vertical integration, and medical loss ratios (MLRs), which could impact members’ contracts with health plans. The comments express support for many of the proposals that are designed to improve beneficiary access to traditional Medicare A and B benefits by constraining plans’ use of internal coverage criteria and artificial intelligence and also seek to ensure beneficiaries' access to the promised MA plan supplemental benefits. They argue for CMS to include skilled nursing facilities (SNFs) and home health agencies in all of its proposed changes to MA plan organization determinations, their appealability, and corresponding payment protections, as some of these proposals were restricted to inpatient hospitals.

LeadingAge National suggested that CMS expand its proposed list of information that MA brokers and agents are required to communicate to Medicare beneficiaries to also require them to inform Medicare beneficiaries that enrolling in an MA/Special Needs Plan (SNP) and using certain supplemental benefits could jeopardize their other government assistance. The letter also presented some additional considerations to CMS’s proposed MLR changes and vertical integration request for information. The MLR changes could dampen MA plans’ interest in entering into certain types of alternative payment arrangements with providers unless they are directly tied to clinical outcomes, and future policies to restrain vertical integration could have negative consequences for current provider-led MA/SNP plans. The comment letter also made recommendations related to the PACE proposals regarding encounter data submissions and pointed out the costs of the proposed technical changes to the nondiscrimination requirements. While changes in the federal landscape may influence the process, in prior years the final rule would be expected in April 2025.