CMS Proposed Rule — CY 2024 Policy and Technical Changes

CMS Proposed Rule- On December 14, 2022, the Centers for Medicare and Medicaid Services (CMS) issued the Proposed Rule for Calendar Year 2024 Policy and Technical Changes that includes revisions to regulations governing Medicare Advantage (MA or Part C), Medicare Prescription Drug Benefit (Part D), Medicare cost plans and Programs of All-Inclusive Care for the Elderly (PACE).

For additional guidance, here’s links to the fact sheet discussing the major provisions and the proposed rule, which was published in the Federal Register on December 27, 2022.

Highlights from the CMS Proposed Rule include:

  • Utilization management requirements focused on ensuring timely access to care
    • Require plans to follow Traditional Medicare coverage decisions and guidelines (National Coverage Determinations, Local Coverage Determinations) when making medical necessity determinations
    • Require plans to provide a public summary of evidence that was considered during the development of the internal coverage criteria used to make medical necessity determinations
    • Require that approval granted through prior authorization processes is valid for the duration of a prescribed course of treatment and that new enrollees who are currently undergoing treatment are provided a minimum 90-day transition period
    • Require plans to establish a Utilization Management Committee to review utilization management policies annually and ensure consistency with Medicare coverage policies
  • Marketing requirements to strengthen beneficiary protections
    • Provisions to protect beneficiaries from confusing and misleading information while ensuring they have the accurate and necessary information to make informed coverage choices (e.g., placing discrete limits around the use of the Medicare name and logo; prohibiting the marketing of benefits in a service area where those benefits are not available)
    • Codify past guidance to safeguard against high-pressure tactics (e.g., clarifying that the prohibition on door-to-door contact still applies)
    • Requirements to strengthen oversight of agent and broker activity (e.g., requiring an oversight plan that monitors agent/broker activities and reports non-compliance to CMS)
  • Revisions to the Star Ratings Program
    • Establish a health equity index (HEI) reward to further encourage improved care for enrollees with certain social risk factors
    • Reduce the weight of patient experience/complaints and access measures
    • Remove guardrails when determining measure-specific-thresholds for non-Consumer Assessment of Healthcare Providers and Systems (CAHPS) measures
    • Modify the Improvement Measure hold harmless policy
    • Include an additional rule for the removal of Star Ratings measures
    • Remove the 60% rule that is part of the adjustment for extreme and uncontrollable circumstances
  • Provisions to advance health equity
    • Clarify the broad application of the policy that services be provided in a culturally competent manner
    • Require each provider’s cultural and linguistic capabilities, including American Sign Language, to be included in provider directories
    • Require the development and maintenance of procedures to offer digital health education to enrollees to improve access to medically necessary telehealth benefits
    • Require activities to address health disparities in quality improvement programs
  • Policies to improve access to behavioral health
    • Add Clinical Psychology, Licensed Clinical Social Worker, and Prescribers of Medication for Opioid Use Disorder, as specialty types that will be evaluated using the time, distance, and minimum provider standards in network adequacy reviews
    • Amend access to services standards to include behavioral health services
    • Codify minimum access wait time standards to apply to both primary care and behavioral health services
    • Clarify that behavioral health services may qualify as emergency services and therefore, not be subject to prior authorization when furnished as emergency services
    • Require notification to members when the member’s behavioral health provider(s) are dropped midyear from networks
    • Require behavioral health care coordination programs to close gaps in behavioral health treatment
  • Additional tools and requirements to improve drug affordability and access in Part D
    • Permit Part D sponsors to immediately substitute certain biological products and authorized generics
    • Promote consistent, equitable, and expanded access to Medication Therapy Management services by changing targeting criteria:
      • Require sponsors to include all core chronic diseases, codify the current 9 core chronic diseases, and add HIV/AIDS for a total of 10 core chronic diseases
      • Lower the maximum number of covered Part D drugs a sponsor may require from 8 to 5 drugs and require sponsors to include all Part D maintenance drugs
      • Revise the cost threshold methodology based on the average annual cost of 5 generic Part D drugs
    • Make the longstanding Limited Income Newly Eligible Transition (LI NET) demonstration program a permanent part of Medicare Part D
    • Implement the provision in the Inflation Reduction Act to expand eligibility for the full Low-Income Subsidy (LIS) group to individuals currently eligible for the partial LIS subsidy

Medicare Advantage Sponsors should review these Proposed Rule changes and consider the impact on its operations.

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