Medicare Advantage Final Rule Addresses Prior Authorization, Health Equity

CMS has finalized a Medicare Advantage rule that aims to increase marketing oversight, streamline prior authorization requirements, and improve access to affordable prescription drugs.

“The Biden-Harris Administration has made exceptionally clear that one of its top priorities is protecting and strengthening Medicare,” CMS Administrator Chiquita Brooks-LaSure said in the press release. “With this final rule, CMS is putting in place new safeguards that make it easier for people with Medicare to access the benefits and services they are entitled to, while also strengthening the Medicare Advantage and Part D programs.”

In the 2024 Medicare Advantage and Part D Final Rule, CMS has prohibited ads that do not mention a specific plan name, ads that use confusing words and imagery, and those that use Medicare logos in a misleading way.

The agency also finalized requirements that ensure beneficiaries receive accurate information about Medicare coverage and know how to access information from other sources. Additionally, the rule strengthens accountability for plans to monitor agent and broker activity, according to CMS.

The final rule addresses the prior authorization process and requires prior authorization approvals to be valid as long as medically necessary and states that coverage denials based on medical necessity must be reviewed by healthcare professionals with relevant expertise before issuing a denial. In addition, the rule requires Medicare Advantage plans to annually review utilization management policies.

The rule directs coordinated care plans to provide a 90-day transition period when a beneficiary undergoing treatment switches to a new Medicare Advantage plan. During this time, the new plan cannot require prior authorization for the active treatment.

The final rule also implements provisions of the Inflation Reduction Act to improve access to affordable prescription drug coverage. CMS is expanding eligibility for the full low-income subsidy benefit to individuals with incomes up to 150 percent of the federal poverty level.

Starting January 1, 2024, individuals who currently qualify for the partial low-income subsidy will have access to the full low-income subsidy. Eligible beneficiaries will have no deductible, no premiums, and fixed, lowered copayments for certain medications under Medicare Part D.

Several policies in the rule aim to address health equity among Medicare Advantage beneficiaries. CMS finalized changes to the Star Ratings program, including a health equity index reward to incentivize plans to improve care for beneficiaries with certain social risk factors. CMS also reduced the weight of patient experience/complaints and access measures.

Plans will be required to provide culturally competent care to more beneficiaries, including those with limited English proficiency; ethnic, cultural, racial, or religious minorities; those with disabilities; and beneficiaries who identify as lesbian, gay, bisexual, transgender, nonbinary, and other diverse sexual orientations or gender identities.

Additionally, CMS is requiring Medicare Advantage organizations to include providers’ cultural and linguistic capabilities in provider directories and include efforts to reduce disparities in their quality improvement programs.

The final rule can be accessed here.