CMS Final Rule: Medicare Advantage (Part C), Medicare Prescription Drug Benefit (Part D), Medicare Cost Plan and Programs of All-Inclusive Care for the Elderly (PACE)

Mary Madison, RN, RAC-CT, CDP
Clinical Consultant – Briggs Healthcare

This final rule will revise the Medicare Advantage (Part C), Medicare Prescription Drug Benefit (Part D), Medicare cost plan, and Programs of All-Inclusive Care for the Elderly (PACE) regulations to implement changes related to Star Ratings, marketing and communications, health equity, provider directories, coverage criteria, prior authorization, passive enrollment, network adequacy, and other programmatic areas. This final rule will also codify regulations implementing section 118 of Division CC of the Consolidated Appropriations Act, 2021, section 11404 of the Inflation Reduction Act, and includes provisions that will codify existing sub-regulatory guidance in the Part C, Part D, and PACE programs.

Effective date: These regulations are effective on June 5, 2023.

AHCA/NCAL recently identified key provisions of this rule that are most pertinent to LTC and PAC providers including:

Medical Necessity and Prior Authorizations

To curb inappropriate MA plan behavior around medical necessity determinations and prior authorizations, CMS codified several policies to ensure concurrence with CMS coverage criteria and continuity of care requirements including:

  • Requiring plans to comply with traditional Medicare coverage criteria when making medical necessity decisions, including national coverage determinations (NCDs), local coverage determinations (LCDs), and other Medicare statutes and general coverage laws, prohibiting plans from using more restrictive internal criteria than those under CMS rules.

  • In the absence of “fully established” Medicare criteria, MA plans may utilize internal criteria using widely used treatment guidelines or clinical literature but must have the criteria, a summary of the evidence used to develop the criteria, a list of the sources, and an explanation of the rationale for the internal coverage criteria publicly facing. CMS refers to MACs as a guide/best practice on how to display coverage criteria publicly.

    • CMS also restricts the use of algorithms such as InterQual, MCG, and similar products to equivalency with Medicare criteria, noting that these products cannot be used to change coverage criteria. 
  • Limiting site of service restrictions and prohibiting MA plans from diverting to settings such as home health in lieu of skilled nursing as recommended by the physician unless the enrollee does not meet traditional Medicare coverage criteria as required by the specific level of care.

  • Specifying that prior authorizations can only be used to confirm the presence of diagnoses or other medical criteria to support medical necessity.

  • Minimizing inappropriate cessation of care by necessitating that approved prior authorizations be valid for the prescribed course of treatment, “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.” This stipulation could have a significant impact on the number of reauthorizations skilled nursing providers would need to submit, especially when a plan of care is authorized. 
  • Requiring a minimum of 90-day transition coverage for enrollees on active treatment on a new plan.

  • Prohibiting plans from denying coverage or payment after the fact based on the lack of medical necessity, if plans had previously provided a prior authorization or pre-service determination, unless there was good cause or fraud to “reopen” the decision.

  • Stipulating that plan clinicians rending an adverse decision have expertise in the relevant medical discipline for the item or service being reviewed.

  • Ensuring that plan policies are appropriate and compliant with Medicare coverage rules by requiring plans to institute a Utilization Management Committee led by the plan’s medical director who annually reviews the plan utilization management policies.

Marketing Restrictions

To ensure beneficiaries are not misled, subject to high pressure sales, and able to make informed decisions on their choice of coverage, CMS codified 21 of the 22 proposals on marketing restrictions. Notably, CMS prohibits plans from utilizing Medicare name, logo or URL which could confuse beneficiaries as to who is endorsing the plan especially on television ads. Additionally, the rule bans sales presentations following educational events, prevents the use of superlatives unless it can be supported by current or prior year documentation, ensures that beneficiaries can make comparative choices based on benefits or cost savings by requiring agents indicate the impact on current coverage, prohibiting the marketing of generalized savings, and restricting marketing of benefits to coverage areas that they are available.

Behavioral Health Access

MA plans are required to provide access to an adequate network of eligible providers, specialists, hospitals, skilled nursing facilities and others to ensure beneficiaries have access to medically necessary services without placing undue burden on beneficiaries pursuing care and services. In keeping with CMS’ commitment to promote behavioral health access this rule adds new provider types, Clinical Psychologists and Licensed Clinical Social Workers to network adequacy requirements, creates network adequacy and wait-time standards for them, and stipulates that prior authorizations cannot be employed for emergent behavioral health situations clarifying that emergencies can be both physical and mental. CMS also requires plans to notify beneficiaries if a behavioral health or primary care provider is no longer in network via written and telephonic communications with more stringent notification requirements and establish care coordination programs to ensure behavioral health a key component of individual beneficiary care planning.

The final rule also codifies policies to promote health equity such as expanding the list of populations requiring culturally competent services, developing procedures for identifying and addressing digital health literacy, and addressing health equity as part of plan quality improvement programs. The rule also makes several changes to the Star Ratings program, establishes a health equity index reward starting 2027 to recognize plans serving vulnerable and underserved populations well and finalizes statutory provisions of the Consolidated Appropriations Act of 2021 and the Inflation Reduction Act by expanding access to low-income subsidies available under Part D to those with incomes up to 150 percent of the Federal poverty limit and making permanent the limited income newly eligible transition (LINET) program.

These policies, when taken as a whole, make measurable strides in mitigating obstacles and delays in medically necessary care for beneficiaries through opaque and complicated processes and reducing provider administrative burden. These policies do also have implications for provider-led Special Needs Plans.