The Centers for Disease Control and Prevention’s Medicare and Medicaid Part D final rule for 2024 is intended to continue the agency’s efforts to strengthen federal oversight of health insurers.
CMS announced the regulation on Wednesday, which includes major changes to standards for metics quality, prior authorization, marketing and health equity. The agency issued the proposed rule in December.
Health and Human Services Secretary Xavier Becerra said: “Today, we are announcing a rule that will crack down on misleading marketing plans by health insurers offering Medicare plans. Advantage, the companies that provide the Part D prescription drug plans and their follow-up organizations. at a press conference on Wednesday.
The stronger regulations announced Wednesday come shortly after CMS released an announcement of final rates in 2024 for Medicare Advantage and Part D, which include less severe payment policies than those announced in 2024. with insurance companies concerned.
“We are carefully reviewing and analyzing the final rule that makes changes to [Medicare Advantage] and Part D program rules for 2024,” health insurance industry association AHIP said in a press release. “As noted in our comment letter on the proposed rule, we supported a number of proposals to strengthen consumer protection while maintaining flexibility, choice, competition. and value. At the same time, we also expressed concern with the proposed changes that would reduce funding or increase costs without benefiting seniors and people with disabilities,” said AHIP.
The Association of Community Linked Programs and the Alliance of Public Health Programs were not available for comment.
“CMS final policy rule for 2024 will support Medicare Advantage’s efforts to close gaps in health equity and deliver high-quality care,” said President and CEO. Better Medicare Alliance executive Mary Beth Donahue said in a press release. “We support provisions to streamline the prior authorization process to ensure timely access to care, as well as steps to ensure transparency and accountability in Medicare Advantage. “
“This regulation will help protect patients and ensure timely access to care,” said Ashley Thompson, senior vice president of public policy analysis and development at the American Hospital Association. time, as well as easing the undue administrative burden on an already stressed healthcare workforce.” , said in a press release.
Marketing
CMS received nearly 40,000 complaints of marketing misconduct from beneficiaries in 2021, a 157% increase from the previous year, the agency previously reported. Based on evidence of these growing problems, the final rule imposes new restrictions on marketing by health insurers, brokers and others. The regulation prohibits advertisements that do not use specific plan names and materials that include potentially misleading words or images, such as the Medicare logo.
star rating
CMS has relaxed its Star Rating quality ratings during the COVID-19 pandemic, contributing to a record number of Medicare Advantage providers with highest scores and largest bonuses in 2022. Health insurance companies have been preparing for this trend to reverse and negatively affect their revenue. CMS will replace the reward factor with a health equity index and reduce patient experience weight and quality score claims. CMS doubled the impact of patient surveys on ratings last year, which insurers cited to explain the drop.
Medicare Centers Director and CMS Deputy Administrator Dr. Meena Seshamani said the health equity provisions and other aspects of the regulation are intended to reward health insurers for ensuring the people from underserved communities receive quality care. CMS estimates the health equity index, starting with a 2027 Star Rating, and new patient experience provisions that will save taxpayers more than $8 billion combined over 10 years.
pre-authorization
The final rule also continues CMS’s efforts to reduce the pre-authorization burden on providers and patients. Insurers must halve the time they need to respond to pre-authorization requests and extend approvals through a patient’s entire course of treatment, and may no longer require pre-approval for patients. emergency behavioral health services.
“We want to ensure that where care is needed, decisions to provide it and pay for it are made by people who know the value of care, not by people who are just trying to save on patient costs,” says Becerra.
Insurers must explain disclaimers and disclose data about their decisions. Patients in active treatment must change insurance carriers at least 90 days before the insurance company can request another prior authorization. Major insurers such as UnitedHealth Group and Cigna have begun to improve their internal processes to accommodate the new regulations.
“This rule removes barriers to care created by complex underwriting and usage management criteria,” says Becerra. plans that fit their needs.”
Mental health, equity, drug costs
CMS also requires insurance companies to notify beneficiaries when primary care or behavioral health providers leave their networks. The network must include clinical psychologists, licensed clinical social workers, and prescribers of opioids.
In addition to including health equity in the Star Rating program, the final rule requires Medicare Advantage insurers to provide access to health care in “a manner that is culture” by including languages spoken by providers in the network directory, providing digital health education, and addressing health disparities in quality improvement programs.
The regulation also implements prescription drug pricing provisions from the Inflation Reduction Act of 2022.
