CMS Final Rule Analysis
On April 5, 2023, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that requires Medicare Advantage (MA) plans to follow traditional Medicare laws for coverage decisions. It also limits the use of prior authorization, mandates continuity of care for Medicare beneficiaries and establishes a Utilization Management (UM) Committee with a heightened standard for adverse medical necessity decisions.
The final rule is technically effective as of June 5 2023, although the new utilization management requirements are applicable to coverage beginning Jan. 1, 2024.
This move is seen as a positive development for healthcare providers, as it brings MA plans closer in alignment with traditional Medicare, which many consider to be the gold standard.
Ensemble Health Partners’ team of subject matter experts created a quick reference guide with clear and easy-to-understand insights into the MA program changes and their potential impact on you.
Key Takeaways
- MA plans must comply with traditional Medicare coverage criteria requirements and standards. This Final Rule makes regulations clearer in what adherence looks likes, codifies what CMS already thinks and limits when MA plans may create and use their own internal coverage criteria. It adds transparency to coverage determinations for providers and beneficiaries.
- MA plans can only use the prior authorization process to validate medical necessity and clinical appropriateness of service. MA plans can’t later deny coverage of an item or service based on medical necessity if it previously issued a prior authorization for that item or service.
- MA plans must establish a UM committee to review and approve all UM policies and procedures to ensure alignment with traditional Medicare. UM policies and procedures cannot be used for basic or supplemental benefits on or after Jan. 1, 2024, unless those policies and procedures have been reviewed and approved by the UM committee.
This new rule introduces several key changes that will promote transparency and consistency in healthcare coverage decisions for MA beneficiaries while ensuring healthcare providers are able to provide the best possible care to their patients. Download this quick reference guide to prepare for these changes and hold MA plans accountable to the new requirements.
View the quick reference e-book here.
These materials are for general informational purposes only. These materials do not, and are not intended to, constitute legal or compliance advice, and you should not act or refrain from acting based on any information provided in these materials. Neither Ensemble Health Partners, nor any of its employees, are your lawyers. Please consult with your own legal counsel or compliance professional regarding specific legal or compliance questions you have.
