Government Cracks Down on Medicare Advantage and Part D

Medicare Advantage and Part D initiatives have faced significant scrutiny in recent times. Due to escalating grievances and apprehensions, the Center for Medicare and Medicaid Services (CMS) has intervened, introducing fresh regulations and promotional standards for these programs to follow henceforth. The intention behind these updates is to usher in enhancements in multiple areas of the programs. Let's delve into the anticipated modifications for beneficiaries in the upcoming period.

Prompt Access to Healthcare Services

The CMS is aiming to refine the prior authorization prerequisites for beneficiaries. From 2024 onwards, these healthcare plans will mandate a preliminary 90-day adjustment window for enrollees who, while already under treatment, transition to a new Part C plan.

Coupled with updated guidelines on the application of prior authorizations, these alterations are expected to enhance the efficiency of the system, benefiting patients, healthcare providers, and insurers alike. 

Additionally, Medicare Advantage plans will be compelled to set up a Utilization Management Committee to assess policies on an annual basis. This move seeks to align more closely with Original Medicare's coverage determinations and protocols.

Updated Compliance Rules

An amendment introduced by CMS emphasizes clearer clinical criteria directives. The aim of this provision is to guarantee that Medicare Advantage participants receive identical medically essential care as is available under Original Medicare. Under these revised regulations, Medicare Advantage plans are obligated to adhere to the same protocols and benefit stipulations as those outlined for Orginal Medicare. 

This directive limits the autonomy of Medicare Advantage plans in implementing their distinct service guidelines. In situations where the coverage prerequisites aren't explicitly defined, Medicare Advantage plans are permitted to formulate in-house coverage standards derived from widely recognized treatment norms or prevailing clinical literature. 

It's important to understand that this is permissible only under specific conditions, with the overarching goal of fostering transparent, evidence-backed clinical choices.

New Medicare Marketing Rules

In a bid to shield beneficiaries from misleading promotional tactics, CMS is introducing tighter marketing standards. Medicare will now prohibit advertisements that omit explicit plan names or utilize wording, visuals, or Medicare emblems that could potentially be ambiguous or misrepresent a particular plan. In a concerted effort to bridge health disparities and champion health equity, CMS has unveiled a definitive rule that broadens the categories of potentially underserved groups that Medicare Advantage entities should cater to, keeping in mind the unique cultural or communal nuances. The motive behind this regulation is to foster a more inclusive environment within Medicare Advantage plans.

For instance, this updated directive seeks to encompass individuals with limited command over English, racial and ethnic minority groups, persons with disabilities, diverse sexual orientations and gender identities, as well as those grappling with economic hardships and societal disparities.

Furthermore, CMS is set to mandate that Medicare Advantage entities intensify their quality enhancement endeavors to incorporate strategies aimed at diminishing disparities.

Addressing the challenge of digital health literacy gaps, MA entities are now required to provide digital health tutorials to their members. Such an initiative is geared towards amplifying their reach to telehealth advantages.

Furthermore, CMS is intensifying its oversight of agent and broker operations to curb aggressive and misleading practices. In tandem with these changes, CMS is also focusing on bolstering beneficiaries' accessibility to accurate Medicare coverage data and other dependable references.

Enhancements to the Star Ratings System

CMS is setting its sights on refining the Star Ratings system for beneficiaries. A fresh regulation has been rolled out that incorporates a health equity index (HEI) incentive set to commence in 2027. 

This innovative directive is designed to motivate Medicare Advantage and Part D plans to elevate the quality of care for beneficiaries, particularly those impacted by societal risk elements.

Promoting Health Equity 

In a concerted effort to bridge health disparities and champion health equity, CMS has unveiled a definitive rule that broadens the categories of potentially underserved groups that Medicare Advantage plans should cater to, keeping in mind the unique cultural or communal nuances. The motive behind this regulation is to foster a more inclusive environment within Medicare Advantage plans.

For instance, this updated directive seeks to encompass individuals with limited command over English, racial and ethnic minority groups, persons with disabilities, diverse sexual orientations and gender identities, as well as those grappling with economic hardships and societal disparities.

In addition, CMS is set to mandate that Medicare Advantage plans intensify their quality enhancement endeavors to incorporate strategies aimed at diminishing disparities.

Addressing the challenge of digital health literacy gaps, Part C plans are now required to provide digital health tutorials to their members. Such an initiative is geared towards amplifying their reach to telehealth advantages.

Better Access to Behavioral Health Services

To increase access to mental health services, CMS is providing network adequacy standards and clarifying the obligations of Medicare Advantage plan organizations concerning the prompt delivery of behavioral health care.

Medicare Advantage providers are now obligated to alert members should their mental health or primary care providers exit the network during the year.

Specific policy alterations include establishing network criteria for Clinical Psychologists and Licensed Clinical Social Workers and ensuring that emergency mental health services bypass the need for prior authorization.

A notable revision from CMS mandates that care coordination initiatives afford identical regard to both mental and physical health services.

This transition is rooted in the aspiration to foster a holistic approach to patient care.

Expansion of Extra Help Eligibility

CMS is broadening the scope for beneficiaries to qualify for the complete low-income subsidy (LIS) perk, commonly referred to as Extra Help. This initiative assists those with limited incomes and resources in managing their prescription costs, covering things like premiums, deductibles, and shared costs.

Starting January 1, 2024, those with earnings amounting to 150% of the federal poverty level (FPL) and who fulfill certain criteria will be entitled to the comprehensive Extra Help benefit.

Essentially, individuals who presently benefit from the partial Extra Help will soon have the chance to receive the full subsidy. As per CMS's statement, this modification is set to "enhance the accessibility to cost-effective prescription drug coverage for an estimated 300,000 economically disadvantaged Medicare beneficiaries."

The revisions presented by CMS hold the promise of effecting considerable enhancements to the Medicare Advantage and Part D initiatives. The primary objectives of these adjustments are to champion health parity, ensure swift healthcare accessibility, shield beneficiaries from misleading promotional strategies, bolster accessibility to mental health services, and incorporate directives from recent legislative enactments like the Inflation Reduction Act of 2022 and the Consolidated Appropriations Act of 2021. 

By addressing these focal points and formulating new Medicare promotional rules, the goal is to elevate the overall service quality and beneficiary experience within the Medicare Advantage and Part D plans.