Medicare Advantage and Part D plans have been the subject of ongoing discussions and critiques. Given the rising number of grievances and issues, The Center for Medicare and Medicaid Services (CMS) has taken action, unveiling new operational rules and promotional standards for these initiatives. These modifications are crafted to foster positive transformations within the programs. Let’s explore the forthcoming adjustments that will impact beneficiaries.
Rapid Healthcare Provision :
CMS is working towards refining the prerequisites for prior authorization for its beneficiaries. Starting in 2024, if an enrollee, already under a treatment regime, opts for a new Advantage plan, a transition span of a minimum of 90 days will be obligatory. With the introduction of fresh guidelines on prior authorization applications, the aim is to overhaul the system that existed before 2024, making it more streamlined for all parties involved: the patient, the medical professional, and the insurer.
Additionally, it’s now imperative for MA plans to constitute a Utilization Management Committee. This committee will be responsible for an annual evaluation of policies, ensuring they are in harmony with the foundational decisions and protocols of Original Medicare.
Updated Regulatory Guidelines :
CMS has unveiled a significant modification, emphasizing clearer clinical criteria directives. The objective behind this is to guarantee that those enrolled in Medicare Advantage receive medical care equivalent to that offered by Medicare.
With this updated directive, MA plans are mandated to adhere to the same protocols and benefit stipulations as set by Traditional Medicare. Consequently, MA plans will face limitations in introducing their unique service guidelines.
In situations where definitive coverage criteria remain elusive, MA entities have the discretion to formulate their own coverage standards, drawing from prevalent treatment protocols or recognized clinical research. It’s crucial to understand that this provision is permissible only under specific conditions, aiming to foster transparency and decisions rooted in evidence.
The Latest Medicare Marketing Directives:
CMS is rolling out fresh marketing standards to shield beneficiaries from misleading promotional tactics. Advertisements lacking a distinct plan name or those utilizing verbiage, visuals, or Medicare emblems that could potentially distort or mischaracterize a plan are no longer permissible.
Furthermore, CMS is intensifying its oversight of the actions of agents and brokers to curb any aggressive practices.
Moreover, one of CMS’s objectives is to enhance beneficiaries’ ability to access accurate information about Medicare coverage and other trustworthy sources.
Star Ratings Program :
CMS is keen on refining the Star rating system for enrollees. A fresh directive introducing a health equity index (HEI) incentive is set to take effect in 2027. The primary goal of this initiative is to motivate Medicare Advantage and Part D plans to elevate the quality of care, with a particular focus on beneficiaries impacted by societal risk elements.
Fair Medical Practices :
In a move to bridge health gaps and champion medical fairness, CMS has unveiled a comprehensive directive that broadens the categories of potentially underserved groups that Medicare Advantage entities must cater to, taking into account their unique cultural or group-specific needs. This directive seeks to foster greater diversity and representation within Medicare Advantage offerings.
For instance, the updated directive aims to encompass individuals with language barriers, diverse racial and ethnic backgrounds, those with disabilities, varied sexual orientations and gender expressions, as well as those grappling with economic challenges.
Furthermore, CMS is set on ensuring that Medicare Advantage entities integrate strategies in their quality enhancement programs that actively work towards diminishing these health disparities.
To address the challenge of digital health unfamiliarity, MA entities are mandated to provide digital health training to their members. This initiative is designed to bolster their utilization of telehealth services.
Expanded Reach for Mental and Behavioral Health Care :
To bolster the availability of behavioral health care, CMS is offering clearer guidelines on the sufficiency of provider networks and the duties of MA entities in delivering these services promptly.
Medicare Advantage providers are now obligated to inform members should their behavioral health or primary care professionals exit the network during the year.
advantage-plan-network-adequacy Among the detailed policy adjustments are the establishment of network criteria for Clinical Psychologists and Licensed Clinical Social Workers, and the stipulation that emergency services related to behavioral health bypass the need for prior approval.
Furthermore, CMS’s latest directive emphasizes that care integration programs should maintain parity between behavioral and physical health services.
The objective behind this revision is to foster a more holistic approach to patient care.
Broader Qualification Criteria for Additional Assistance :
CMS is broadening the criteria for beneficiaries to access the comprehensive low-income subsidy (LIS) benefit, commonly referred to as “Extra Help.” This initiative assists those with limited incomes and resources in managing their prescription costs, covering aspects like premiums, deductibles, and other expenses.
Starting from January 1, 2024, those with incomes amounting to 150% of the federal poverty benchmark and who fulfill certain conditions will be eligible for the complete Extra Help financial aid.
Essentially, individuals who were previously only eligible for a partial subsidy under Extra Help will now have access to full financial support. As per CMS’s statement, this modification aims to “facilitate more affordable prescription medication access for an estimated 300,000 economically challenged Medicare beneficiaries.
Dedication to Enhanced Health Insurance Provision :
Updates introduced by CMS have the potential to enhance both the Medicare Advantage and Part D initiatives significantly. These revisions are designed to promote medical fairness, ensure prompt healthcare services, shield beneficiaries from misleading promotional strategies, amplify the availability of behavioral healthcare, and incorporate directives from recent laws, including the 2022 Inflation Reduction Act and the 2021 Consolidated Appropriations Act. By addressing these pivotal issues and formulating new promotional standards for Medicare, the aspiration is to elevate the quality and overall beneficiary experience within Advantage and Part D schemes.
Essential Highlights :
- For the 2024 calendar year, Advantage and Part D schemes will undergo rigorous scrutiny as they roll out these updates.
- Adjustments in prior authorization and revamped promotional standards aim to curb misleading marketing strategies moving forward.
- Enhancements in coverage and the broadening of the ‘Extra Help’ initiative are anticipated to broaden healthcare access for numerous beneficiaries.