CMS 4201 F

On April 5, 2023, CMS issued the 2024 Medicare Advantage and Part D Final Rule (CMS-4201-F)

In April, CMS released Final Rule 4201-F with staggered effective dates from June onward through 2027, bringing noteworthy changes to home health care and the wider industry. These changes are significant because they aim to ensure Medicare beneficiaries have reliable and timely access to necessary medical care. Let’s dive into the four major adjustments made by CMS to improve Medicare Advantage (MA) plans:

1. Ensuring Timely Access to Care:

The new rules address utilization management (UM) and prior authorization processes to align MA plans with Traditional Medicare coverage. The aim is to provide beneficiaries with the necessary care without interruption, especially during transitions between plans or from Traditional Medicare to MA plans. A key provision is a minimum 90-day transition period to prevent disruption of ongoing treatment for new enrollees.

2. Protecting Beneficiaries:

CMS is introducing safeguards for beneficiaries against inconsistent UM practices and deceptive marketing tactics. A Utilization Management Committee will be established to annually review policies to ensure they’re consistent with Traditional Medicare standards. Additionally, efforts are being made to improve transparency and understanding of coverage details, including mandating a 30-day notice for beneficiaries before the termination of a provider’s contract.

3. Advancing Health Equity:

The Final Rule mandates that Medicare Advantage organizations enhance their directories to reflect greater cultural and linguistic capabilities. This is to ensure all patients, regardless of cultural or linguistic background, receive high-quality care and to address disparities in access to health care services among MA enrollees.

4. Improving Access to Behavioral Health:

CMS is focusing on increasing access to behavioral health services by holding MA organizations accountable for providing adequate in-network options. This includes the requirement for care coordination programs that integrate community, social, and behavioral health services, promoting a level of access similar to that of acute care.

  1. Medicare Advantage Must Adhere to Two-Midnight Rule

CMS has stated that Medicare Advantage (MA) plans are required to follow the same coverage criteria as Traditional Medicare, which includes National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and existing guidelines concerning inpatient admissions, as well as the Two-Midnight Rule for establishing the necessity of covered “basic benefits” under Parts A and B. An MA plan is obligated to cover an inpatient admission when the patient’s complex medical situation, as documented in their medical records, leads the admitting physician to expect that the patient will need hospital care spanning more than two midnights, known as the Benchmark rule.

MA plans must adhere to established coverage criteria for inpatient admissions as outlined in 42 CFR 412.3, including the procedures that are deemed ‘inpatient only,’ the conditions for Skilled Nursing Facility Care and Home Health Services under 42 CFR part 409, and the criteria for Inpatient Rehabilitation Facilities coverage detailed in 42 CFR 412.622(a)(3).

While MA plans are not obliged to automatically assume that an inpatient stay is medically necessary under the two-midnight presumption—which is typically used to direct review activities by contractors—CMS has not restricted MA organizations from evaluating such cases. In their reviews, MA plans must still use the Benchmark rule as the basis for assessing the medical necessity of the inpatient admissions.

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