New Medicare Advantage guidance, emphasis on health equity on the horizon for 2024

By Susan Rupe

New guidance for Medicare Advantage plans and an increased emphasis on social determinants of health are among the issues that health care providers and Medicare beneficiaries can expect to see in 2024.

Cheyenne Zychowski, managing editor of MCG Health, discussed some upcoming changes in Medicare during a recent AHIP webinar.

Medicare Advantage guidance

Some Medicare Advantage organizations’ denial of prior authorizations to obtain care led to the Center for Medicare and Medicaid Services to issue CMS Rule 4201-F in April. This rule follows a 2022 report by the Office of Inspector General expressing concern about the potential incentive for Medicare Advantage organizations to deny access to services and deny payments to providers in an attempt to increase profits.

Zychowski said the inspector general’s report showed that of 250 prior authorization denials, 13% met Medicare coverage rules and would have been approved under Medicare fee-for-service. Of 250 payment denials, 18% met Medicare coverage rules and Medicare Advantage Organization billing rules.

Patient groups, consumer groups, provider groups and provider group associations contended that prior authorization sometimes can create a barrier to obtaining care, Zychowski said. These groups also are concerned that some of these prior authorization processes are causing delays in receiving care or are causing inappropriate denials.

Rule 4201-F is aimed at putting Medicare Advantage in greater alignment with traditional Medicare, she said. Under the rule, Medicare Advantage organizations must cover Part A and Part B benefits on the same conditions as traditional Medicare. In addition, Medicare Advantage organizations must follow the same CMS guidance and rules that apply to traditional Medicare patients unless a specific Medicare Advantage law supersedes those rules.

Where prior authorization is concerned, the rule:

Limits the use of prior authorization to confirm the presence of diagnoses or other medical criteria or ensuring that an item or service is medically necessary.
Prohibits Medicare Advantage plans from requiring prior authorizations for an active course of treatment for at least 90 days when a patient switches MA plans.
Requires all Medicare Advantage plans to establish utilization management committees to ensure consistency with traditional Medicare’s national and local coverage decisions and guidelines.
Requires that prior authorization approvals remain valid “for as long as medically reasonable and necessary to avoid disruptions in care in accordance with applicable coverage criteria, the patient’s medical history and the treating provider’s recommendation.”

Social determinants of health

CMS continues to focus on social determinants of health to advance health equity, Zychowski said. Expect to see Medicare put a greater emphasis on addressing its beneficiaries’ unmet social needs including food insecurity, housing instability and transportation barriers.

“Medical care alone is insufficient for ensuring better health outcomes,” she said.

CMS has established a health equity index for Medicare Advantage plans. Medicare Advantage organizations must closely examine its members’ social risks and take action to address them. Medicare Advantage organizations’ performance in addressing these needs will factor into their 2027 Medicare Advantage star ratings.

End of PHE, new benefits

The COVID-19 public health emergency ended May 11, and that means some changes to Medicare as well, Zychowski said. Some temporary waivers impacting care come to an end on Dec. 31, 2023, while waivers that affect telehealth continue through Dec. 31, 2024.

Medicare will have no originating site or geographic restrictions for any telehealth service through Dec. 31, 2024, meaning that Medicare patients can receive telehealth services in their home. After that date, there will be no originating site or geographic restrictions for behavioral or mental telehealth services, but those restrictions may apply to other telehealth services.

In addition, new Medicare benefits that will begin on Jan. 1, 2024, include:

Chronic pain management and treatment services.
Coverage of lymphedema compression treatment items.
Expansion of mental health care options to include coverage of marriage and family therapy as well as mental health counseling.

Susan Rupe is managing editor for InsuranceNewsNet. She formerly served as communications director for an insurance agents' association and was an award-winning newspaper reporter and editor. Contact her at [email protected]. Follow her on Twitter @INNsusan.