CMS Enhances MA Beneficiary Protections

Reimbursement; CMS; Medicare; Medicare Advantage

The Centers for Medicare & Medicaid Services (CMS) last week released the Contract Year (CY) 2025 Medicare Advantage and Part D Final Rule, which finalized revisions to policies governing Medicare Advantage (MA), Part D, Medicare Cost Plans, and the Program for All-Inclusive Care for the Elderly (PACE).

AHCA/NCAL successfully advocated for specific policies within the rule to help ensure individuals in a MA plan have access to high quality care and timely, medically necessary services. These include:  
  • Right to Fast Track Appeals of Non-Hospital MA Plan Decisions: Beneficiaries have the right to fast-track appeals by Quality Improvement Organizations instead of the MA plan for terminated non-hospital services even if it is untimely or the beneficiary has left the facility.
  • Network Adequacy Exception Request for Facility-based I-SNPs: We anticipate this proposal may help mitigate some of the network adequacy barriers experienced by smaller plans. CMS recognizes the different care utilization patterns for beneficiaries who reside in a skilled nursing facility for 90 days or more. It establishes a new exception process for Facility-based ISNPs on a single contract ID if:
    • The facility-based I-SNP submits evidence of its inability to successfully negotiate and establish a contract with a provider, including individual providers and facilities, due to the way enrollees in the I-SNP receive care; or
    • The facility-based I-SNP provides sufficient and adequate access to basic benefits through additional telehealth benefits and substantial and credible evidence that sufficient and adequate access is provided when offering specialty telehealth benefits to fulfill network adequacy standards. 

CMS also finalized several other proposals, including:

  • Policies that advance Medicare-Medicaid integration;
  • Access expansion to behavioral health;
  • Transparency on supplemental benefits;
  • Mid-year notification for enrollees of unused supplemental benefits;
  • Parameters on agent/broker compensation; and
  • Expansion of health equity requirements on MA utilization management committees.
The CMS fact sheet provides additional information, and see the full final rule in the Federal Register

These regulations are effective June 3, 2024, and are applicable to coverage beginning January 1, 2025, with some exceptions to certain marketing and communication and D-SNP policies.

CMS also reminded stakeholders of its previously released request for information on Medicare Advantage data, with the comment period ending May 29, 2024. AHCA/NCAL will submit comments.

This final rule comes following release of the CY 2025 Medicare Advantage Rate Announcement earlier last week. CMS estimates that MA plans will experience (on average) a 3.7% increase ($16 billion) in revenues but reduced MA benchmark rates. More information about this final rule is available here

Please contact Nisha Hammel at AHCA/NCAL with any questions.