What’s in the rest of the 2024 Medicare final rule?

Changes to Medicare Advantage and Part D regulations for 2024 have been finalized by CMS, or the Centers for Medicare & Medicaid Services. Many, including changes to acceptable coverage, prior authorization, marketing, star ratings, and behavioral health regulations, are set to build a better experience for beneficiaries. 

Acceptable coverage criteria
First, the final rule gives additional specifications on acceptable coverage. When making a medical decision, care providers use clinical practice guidelines. These guidelines combine and process data from innumerable clinical trials into a guidance system that can be more easily applied to the real-life scenarios that medical professionals experience each day. These guidelines, along with other factors, are used not only to determine what care works best for the patient, but also what coverage is appropriate for health care plans. What do these have to do with Medicare Advantage plans? According to this year’s final rule, MA plans must comply with these practice guidelines along with national and local coverage determinations when acceptable coverage criteria is being determined. This practice has already been established with Traditional Medicare, but is now being applied to MA plans as well.  

If there are no established coverage criteria, MA organizations may create internal coverage criteria based on current evidence. The criteria must be made readily available for review by CMS, enrollees, and providers. MA plans and the decisions made surrounding the coverage they provide should be more transparent and consistent after this rule applies.

Prior authorizations
The next item involves the coordination between prior authorization and continuity of care. CMS dictates that coordinated care plans can only require prior authorization to confirm a diagnosis or if a service or an item is medically necessary. Coordinated care plans must provide at least 90 days for transitions between MA plans if the beneficiary is undergoing treatment during that transition. If the beneficiary does transition between plans, the new plan cannot require prior authorization for treatment currently ongoing. 

Prior authorizations will be forbidden from interrupting care. A prior authorization now must extend for the entire time the beneficiary will need it to maintain care, along with applicable coverage criteria, medical history, and the provider’s recommendation. 

CMS also looks to protect beneficiaries from the misuse of prior authorizations. All MA plans must establish a Utilization Management Committee to annually review all policies’ compliance with national and local coverage decisions and guidelines. 

Star ratings
Adjacent to marketing, the star ratings program will be adjusted. Starting in 2027, a health equity index reward will be created to encourage MA and Part D plans to improve care for those beneficiaries who experience some specific social risk factors  . This process will then reduce the reward attached to performance consistency. Patient experiences, complaints, and access measures will affect the star rating of a plan less, bringing the formula for star ratings closer to other CMS quality programs. Some types of Star Ratings will be removed, and the 60 percent rule for adjustments based on extreme and uncontrollable circumstances will be also be removed. 

Access to equitable care
CMS has expanded the list of those who must receive culturally competent services to include those with limited English skills; ethnic, cultural, racial, or religious minorities; disabled populations; LGBTQ+ populations; rural populations; or those who are affected by persistent poverty or inequality. MA plans must provide cultural and linguistic capabilities in their directories. 

MA plans must offer digital health education services to boost access to medically necessary telehealth benefits. 

Finally, MA plans must include an effort to reduce disparities in their quality improvement plans. 

Behavioral health changes 
Widening access to telehealth has been another goal for CMS, and this new final rule highlights that. Clinical Psychology and Clinical Social Work will be considered specialty types. This opens these services up to have network adequacy evaluations, but also allows for additional benefits, such as telehealth credits. These changes regarding behavioral health networks  will  require beneficiaries are notified if their behavioral health provider is dropped from that network. General access services will now include behavioral health services. Appointment standards for behavioral health will now be codified, and can no longer be subject to prior authorization. These behavioral health services can now establish coordination of care programs with physical health. CMS aims to create a whole-person care system with these changes. 

There's something to look forward to
Within the next few years, beneficiaries should have a more streamlined experience when choosing a MA plan, switching MA plans while receiving care, and accessing behavioral health services. The plans they choose should have more clarity on the regulatory process.  What about the marketing changes? Click here to read up on that.