CMS Final Rule—CY 2024 Policy and Technical Changes

April 13, 2023

The Calendar Year 2024 Policy and Technical Changes (CMS Final Rule) was released by the Centers for Medicare & Medicaid Services (CMS) on April 12, 2023. The final rule includes major revisions to regulations governing Medicare Advantage, Medicare Prescription Drug Benefit, Medicare Cost plans, and Programs of All-Inclusive Care for the Elderly (PACE). Some proposed rules were not finalized; however, they may be in the future.

A fact sheet discussing the major provisions of the rule can be found here: 2024 Medicare Advantage and Part D Final Rule (CMS-4201-F) | CMS

Highlights from the CMS Final Rule include:

Utilization Management Requirements (§§ 422.101, 422.112, 422.137, 422.138, and 422.202)
- Prior authorization policies for coordinated care plans, may only be used to confirm the presence of diagnosis or other medical criteria and/or ensure that the item or service is medically necessary
- Prior authorization approvals must be valid for as long as medically necessary to avoid disruption in care in accordance with applicable coverage criteria, the member’s medical history, and the treating provider’s recommendation, and that plans provide a minimum 90-day transition period when a new member who is currently undergoing an active course of treatment switches to a new MA plan
- Requires plans to comply with national coverage determinations (NCDs), local coverage determinations (LCDs), and general coverage and benefit conditions include in Traditional Medicare laws
- All plans must establish a Utilization Management Committee to review utilization management policies annually and ensure consistency with Medicare coverage policies
Marketing Requirements effective September 30, 2023 (Subpart V of Parts 422 and 423)
- Notification to members annually, in writing, of the ability to opt out of phone calls regarding MA and Part D plan business
- Requiring agents to explain the effect of an enrollment choice to enrollees on their current coverage
- Simplifying plan comparisons by requiring medical benefits in a specific order and listed at the top of the Summary of Benefits
- Third-party marketing organizations (TPMOs)
  - Limits the requirement to record calls between third-party marketing organizations (TPMOs) and beneficiaries to marketing/sales and enrollment calls
  - Requires TPMOs to list or mention all of the MA organization or Part D sponsors that they represent on marketing materials
  - Requires MA organizations and Part D sponsors to have an oversight plan monitoring agent/broker activities and report agent/broker non-compliance to CMS
  - Modifies the TPMO disclaimer to add SHIPs as an option for beneficiaries to obtain additional help and to state the number of organizations represented by the TPMO as well as the number of plans
- Limits the timeframe when a sales agent can call a potential enrollee to no more than 12 months following the date the enrollee first asked for information
- Scope of Appointment (SOA)
  - Prohibits collection of SOA cards at educational events
  - Requires 48 hours between an SOA and an agent meeting with a beneficiary, with exceptions for beneficiary-initiated walk-ins and the end of a valid enrollment period
  - Clarifies that the prohibition on door-to-door contact without a prior appointment still applies after the collection of a business reply card (BRC) or SOA
- Translation and Accessible Format Requirements (§§ 422.2267 and 423.2267)
  - Plans must provide non-English or accessible format materials on a standing basis upon receiving a request for materials or otherwise learning of the member’s primary language and/or need for accessible format
  - Fully integrated dual-eligible special needs plans (FIDE SNPs), highly integrated dual-eligible special needs plans (HIDE SNPs), and applicable integrated plans (AIPs) must translate required materials into any languages required by the Medicare translation standard plus any additional languages required by Medicaid
- Enrollee Notification Requirements for Provider Contract Terminations (§§ 422.111 and 422.2267)
  - Establishes specific enrollee notification requirements for no-cause and for-cause provider contract terminations and adds specific enrollee notification requirements when primary care and behavioral health provider contract terminations occur
  - Specifies the content and procedural requirements for notification to enrollees to increase enrollee protections when MA network changes occur and raise the standards for the stability of enrollees’ primary care and behavioral health treatment

Medicare Advantage Sponsors should review these changes, as well as other provisions in the rule and consider the impact on its operations.

Highlights from the CMS Final Rule include:

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