For skilled nursing providers, these are the most targeted prior authorization guardrails to date. But their impact on skilled nursing providers remains to be seen.
CMS data indicates that MA plans overturn approximately 80% of claim denials when appealed, yet less than 4% of denied claims are ever appealed. The proposed rule would define “internal coverage criteria” to clarify when MA plans may apply utilization management, require that internal coverage policies be transparent and publicly available, strengthen notice requirements ensuring providers and enrollees receive decision notifications, eliminate plan discretion to reopen approved inpatient hospital authorizations, and clarify coverage determinations made contemporaneously with service delivery, including level-of-care decisions. The rule also proposes requiring MA plans to ensure services are provided equitably regardless of the delivery method used, including AI-driven tools, in compliance with existing non-discrimination requirements.
— CMS.gov, November 26, 2024
Centers for Medicare & Medicaid Services. “Contract Year 2026 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicare Cost Plan Program, and Programs of All-Inclusive Care for the Elderly (CMS-4208-P).” CMS.gov, 26 Nov. 2024. https://www.cms.gov/newsroom/fact-sheets/contract-year-2026-policy-and-technical-changes-medicare-advantage-program-medicare-prescription.
View the rule in the Federal Register.
‘Inappropriate’ Prior Authorization Targeted in Latest CMS Proposed Rule, but Will It Ever Go Live?
“What this means is that more patients could likely have access to care if inappropriate prior authorizations did not block it,” CMS Deputy Administrator Meena Seshamani, MD, PhD, said on a call with reporters Tuesday morning. She noted the new rule would clarify when MA plans could apply utilization management and require them to have “transparent and easily available” internal coverage policies. Plans will have to make enrollees aware of their appeal rights, while the agency said it is also addressing “after-the-fact” overturns that can impact payment to providers, including nursing homes.
— McKnight’s Long-Term Care News, November 27, 2024
CMS Issues ‘Guardrails’ to Improve Medicare Advantage Access and Transparency
The Centers for Medicare & Medicaid Services (CMS) is taking new steps to improve Medicare Advantage (MA) access and transparency, including reforms to prior authorizations and the use of AI tools to deny coverage, as outlined in the 2026 Medicare Advantage and Part D proposed rule. CMS Deputy Administrator Meena Seshamani emphasized a striking pattern: “MA plans overturn 80% of their decisions to deny claims when those claims are appealed to the plan. However, these data also show that less than 4% of denied claims are appealed in the first place.”
— Skilled Nursing News, November 26, 2024
Medicare Advantage Prior Authorization, Marketing Limits Proposed
Medicare Advantage insurers would no longer be allowed to reconsider approved prior authorization requests for inpatient hospital admissions. Insurers using automated reviews must “provide equitable access to services and not discriminate on the basis of any factor that is related to the enrollee’s health status.” The regulation also addresses concern that “the current narrow definition of marketing has created a loophole” enabling “misleading and confusing marketing practices” to escape CMS oversight.
— Modern Healthcare, November 26, 2024
BREAKING: CMS Proposes More Medicare Advantage ‘Guardrails’
The Centers for Medicare & Medicaid Services announced Tuesday it is pursuing further limits on Medicare Advantage plans’ use of prior authorization and artificial intelligence as “barriers to care.” Officials billed the Contract Year 2026 MA and Part D proposed rule as a response to mounting calls from consumers, providers and members of Congress to institute reforms related to coverage decisions. “Skilled nursing providers have struggled, and continue to struggle, with Medicare Advantage coverage decisions that are based solely on AI algorithms,” Nisha Hammel, vice president of reimbursement policy and population health at the American Health Care Association told McKnight’s Long-Term Care News.
— McKnight’s Long-Term Care News, November 26, 2024
LeadingAge Statement: Contract Year (CY) 2026 MA and Part D Proposed Rule (CMS-4208-P)
“While we are continuing to review the details in this 700-plus page document, we can say with certainty that the further explanation and details provided on these areas bring us closer to the achievement of a shared goal: MA that works for all–enrollees, providers, taxpayers and plans. Yet more work remains. More must be done on PAs and concurrent reviews for post-acute care providers.”
— LeadingAge, November 26, 2024
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