The coalition of post-acute care associations and the Center for Medicare Advocacy met January 3rd with roughly 15 CMS leaders and staff who work in the Center for Medicare and oversee the Medicare Advantage program to articulate our concerns that MA plan policies and practices may not change with the new MA regulations that took effect January 1, 2024, and offering our assistance in identifying areas of non-compliance or rules that require further refinement. We provided an illustrative example regarding interrupted stays in nursing homes that shows how plans either directly, or through third parties such as NaviHealth, are failing to comply with new policies that are designed to ensure beneficiaries timely access to Medicare A and B benefits including reducing the number of required prior authorizations for a patient’s course of treatment. We sought answers on what enforcement actions we could expect from CMS to ensure plan adoption of these critical changes to coverage determinations and utilization management practices.
CMS shared that it has a multi-pronged strategy based upon historical practices including plan education, developing some FAQs to provide further clarification (pending), combined with an enhanced auditing process to enforce the new measures related to access to care and services. Typically, CMS conducts routine audits on a subset of the largest MA plans in a three-year rotation. This year, nearly all plans will be audited to examine compliance with the coverage and utilization management policies contained in the CY2024 rule. This time, CMS expects compliance in the first year of implementation and noted it will use the full array of tools in its arsenal including civil monetary penalties, corrective action plans, publicly reporting plans not in compliance, and in cases of systemic problems, applying sanctions that prohibit plans from enrolling new beneficiaries.
CMS welcomed support from the PAC coalition to funnel information on non-compliance trends observed by our providers around the country. CMS also encouraged the coalition to maintain an ongoing dialogue providing feedback on regulations that still aren’t working. CMS made it clear that they intend to take these audits very seriously and conduct thorough reviews of plans’ compliance with the new regulations, which are expected to improve MA enrollees’ access to necessary Medicare benefits and reduce some of the administrative burden for providers. Send examples of Medicare Advantage plan issues to Kylee Childs.
