Proposed Changes to Medicare Advantage Utilization Management

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AUTHOR – Kristen Lunde

On December 14, 2022, the Centers for Medicare & Medicaid Services (CMS) released a proposed rule containing a number of significant policy and technical changes to the Medicare Advantage (MA) and Part D programs for 2024. Among other changes to the programs, CMS proposes to create additional guardrails for MA utilization management tools and coverage decisions, which have important implications for plans, providers, and beneficiaries.

Key provisions related to MA plans’ utilization management practices include: include:

  • Prohibiting MA plans from denying coverage for care in specific settings unless the coverage criteria under traditional Medicare is not met for that setting. For example, a plan could not redirect a beneficiary to home health care if there is an order for care in a skilled nursing facility (SNF) and the beneficiary meets SNF coverage criteria.
  • Requiring MA plans to establish a committee responsible for reviewing utilization management policies and procedures at least annually for accordance with traditional Medicare coverage.
  • Requiring MA plans’ prior authorization policies to promote continuity of care by providing transition periods for new enrollees and applying approvals to full courses of treatment.

    CMS recently released another proposed rule, Advancing Interoperability and Improving Prior Authorization Processes that would modify MA and other federally funded health plans’ use of prior authorization Taken together, these rules would pursue similar goals to the Improving Seniors’ Timely Access to Care Act, which passed the House of Representatives in September 2022.

    While much of the effect of these policies will come down to implementation, these proposals would improve the care experience for beneficiaries and their caregivers by clarifying coverage criteria, streamlining utilization management processes, and increasing transparency. ATI is closely tracking these proposals and their potential impact for plans, providers, and beneficiaries.

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