Medical Advantage Final Rules

The 2024 Medical Advantage Final Rules: A Brief Guidance

The Centres for Medicare & Medicaid Services (CMS) issued its 2024 Final Rule for Medicare Advantage on April 5, which will help stop fraudulent marketing practices, streamline prior authorization procedures, and provide much-needed access to behavioral healthcare. Furthermore, this critical legislation strives for health justice by implementing the Inflation Reduction Act principles that significantly reduce prescription medication prices. Let us go deeper into what these essential adjustments are intended to accomplish.

Reduce deceptive marketing tactics while ensuring authenticity and transparency.

Regarding Medicare Advantage plans 2024 and Part D coverage, CMS protects seniors against confusing and deceptive advertising practices. That’s why commercials without a particular plan name are prohibited, as are ads that employ government-issued items, logos, or information confusingly. This shift was precipitated by the proliferation of television advertising urging enrollment in MA plans using wording that recipients may misinterpret.

CMS has finalized a regulation that tightens the responsibility for plans monitoring agent and broker conduct to safeguard beneficiaries and ensure they receive correct information about Medicare coverage. Of the 22 provisions suggested in December, 21 were finalized, 17 were implemented as written, and four were modified before implementation. According to an official information sheet issued by CMS, this new regulation will safeguard beneficiary safety while boosting openness in all healthcare operations.

Remove impediments to care caused by complicated processes.

Removing Impediments | The ScrumMaster State of Mind Model | InformIT

The new rule simplifies previous authorization standards and decreases interruption for enrolled people by guaranteeing that granted authorizations stay valid until medically essential to avert service discontinuation. Furthermore, MA plans must evaluate their utilization management policies every year, with health professionals versed in the subject having the ultimate word on rejections based on medical necessity before issuing a denial. These regulations support CMS’ proposed rule Advancing Interoperability and Improving Prior Authorization Processes.

CMS has established necessary safeguards on utilization management procedures and coverage criteria to ensure that MA (Medicare Advantage) subscribers receive the same clinically essential treatment as regular Medicare recipients. This project is under the current Office of Inspector General guidelines. CMS requires compliance with national coverage determinations (NCD) and local coverage determinations (LCD), in addition to the general requirements of Medicare rules, to ensure that MA plans to fulfill quality criteria for essential benefits.

If the coverage requirements are unclear, Medicare Advantage organizations can develop internal qualifications based on publicly available treatment recommendations and clinical research. Furthermore, CMS has clarified the parameters under which MA plans can use interval coverage criteria for making medical necessity judgments. The administration has stated that allowing publicly accessible internal coverage criteria in specified instances is critical for MA plans to make transparent and evidence-based clinical judgments equal to conventional Medicare.

Furthermore, CMS finalized a regulation that streamlines prior permission procedures and adds continuity of care criteria to help beneficiaries avoid interruptions. Prior authorization under a coordinated care plan is only required to validate a diagnosis or other medical criteria and to guarantee that any item or service is medically essential. When an enrollee receiving treatment transfers to a new MA plan, coordinated care plans must provide at least 90 days of uninterrupted therapy. Similarly, the new MA plan shall not need authorization from the active treatment court during this transition.

To ensure that prior authorization is used effectively, CMS requires all MA plans to organize a utilization management committee to evaluate policies yearly and verify consistency with Medicare’s standard national and local coverage choices and criteria. The final rule requires that prior authorization requests be approved for as long as necessary to avoid interruptions in care and are based on applicable coverage criteria, patient medical history, and treating provider recommendations to ensure that the “course of treatment” is clearly defined.

Increase Access to Behavioural Health Services.

Clinical psychologists and licensed clinical social workers have been added to the list of evaluated specializations to strengthen the quality of MA’s behavioral health services. Furthermore, certain specialty kinds will receive a telehealth credit of 10%. Furthermore, CMS has established wait time criteria for primary care and behavioral health treatments and more specified notification requirements from plans when specific providers are withdrawn from their networks. Furthermore, the CMS will require that most MA plans incorporate behavioral health services in their care coordination programs, ensuring that mental health is essential to individual-focused healthcare planning.

Encourage Health Equity And Equal Opportunity For All.

PechaKucha Presentation: Health Equity

CMS, committed to promoting health equity for everyone, has reaffirmed its commitment to providing access and assistance to people who have traditionally been ignored or mistreated due to poverty and inequality. Individuals and groups from diverse backgrounds, such as ethnic or cultural minorities, LGBTQ+ members, people with disabilities, limited English proficiency or reading skills, and those living in rural areas suffering from poverty and inequality, are disproportionately impacted by the agency’s current regulations.

CMS has acknowledged that a lack of digital health literacy, particularly among those most affected by health inequities, impedes telehealth access, widening the care gap. To address this issue, CMS is mandating MA plans to create processes that provide members with digital education to increase access to medically essential covered benefits. Furthermore, they are improving current best practices by requiring MA organizations to include providers’ cultural and language competencies when building provider directories. 

According to the government, this change will improve the quality and efficiency of provider directories, particularly for non-English speakers, those with low English proficiency, and people who use American Sign Language. Furthermore, CMS has mandated that MA plans improve their Quality Improvement Programmes to eliminate disparities.

The new prescription drug law enacted under the Inflation Reduction Act is now in effect.

The essential regulation of the Inflation Reduction Act is being implemented to assure greater access to affordable prescription medication coverage for almost 300,000 low-income persons. Those who qualify and earn less than 150 percent of the federal poverty line will get the entire low-income subsidy benefit (often known as “extra help”).

Eligible subscribers will get total low-income subsidies with no deductible or premiums beginning January 1, 2024 (if enrolled in a benchmark plan). Furthermore, patients will get fixed and reduced rates to minimize copayments for some prescriptions under Medicare Part D.

Make Significant Improvements to Star Ratings.

Stakeholders laud 'incremental improvement' to star ratings methodology but  call for further updates | Fierce Healthcare

The CMS has chosen unique approaches for its Star ratings program to strengthen quality healthcare. Beginning with the 2027 Star Ratings, such changes will include a Health Equity Index Reward, which will compensate Medicare Advantage and Part D plans for providing exceptional care to underserved populations while requiring those same plans to provide culturally competent care to a broader range of patients. Furthermore, they must provide equal access to persons with poor English proficiency by creating specific content in other forms and languages.


The above rules will help you immensely if you apply for medical advantage plans shortly. So go through them thoroughly before choosing any medical benefits.

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