On April 5, 2023, the Centers for Medicare & Medicaid Services (CMS) published the Medicare Advantage and Part D final rule. This rule summarizes finalized changes to the Medicare Advantage (Medicare Part C), prescription benefit coverage (Medicare Part D), Medicare Cost Plan, and Programs of All-Inclusive Care for the Elderly (PACE). The final rule also codifies regulations from the Consolidated Appropriations Act of 2021 and part of the Inflation Reduction Act.

Key revisions from the final rule are summarized below.

Marketing practices

CMS prohibits advertisements that do not mention a specific plan name. Advertisements also are prohibited from using in a misleading way the Medicare name, CMS logo, or products and information issued by the federal government, including the Medicare card. The rule also provides for additional requirements to increase accountability for plans to monitor agent and broker activity.

Prior authorization and utilization management

CMS has changed prior authorization requirements by requiring that a granted prior authorization approval remains valid for as long as medically necessary, requiring Medicare Advantage plans to annually review utilization management policies. The agency also finalized that denials of coverage based on medical necessity must be reviewed by health care professionals with relevant expertise before a denial can be issued. CMS believes these policies complement proposals in its proposed rule, “Advancing Interoperability and Improving Prior Authorization Processes.”

Behavioral health access

CMS requires clinical psychologists and licensed clinical social workers to be on the list of evaluated specialties in Medicare Advantage. The rule also finalizes wait time standards for behavioral health and primary care services and more specific notice requirements from plans to patients when these providers are dropped from their networks. CMS also will require most types of Medicare Advantage plans to include behavioral health services in care coordination programs.

Health equity

The rule establishes a health equity index in the Star Ratings program that will reward Medicare Advantage and Medicare Part D plans that provide excellent care for underserved populations. Plans also will be required to provide culturally competent care to an expanded list of populations and to improve equitable access to care for those with limited English proficiency, through newly expanded requirements for providing materials in alternate formats and languages.

Inflation Reduction Act and Consolidated Appropriations Act, 2021 implementation

The rule expands eligibility for the full low-income subsidy benefit (also known as “Extra Help”) to individuals with incomes up to 150% of the federal poverty level who meet eligibility criteria. Beginning Jan. 1, 2024, this change will provide the full low-income subsidy to those who would currently qualify for the partial low-income subsidy. As a result of this change, eligible enrollees will have no deductible, no premiums (if enrolled in a “benchmark” plan), and fixed, lowered copayments for certain medications under Medicare Part D.

The complete 2024 Medicare Advantage and Part D final rule fact sheet is available on the CMS website, where you also can download the CMS Announcement of Calendar Year (CY) 2024 Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies.

This update was prepared in conjunction with our colleagues at McDermott Will & Emery. Members may send specific questions regarding this final rule to coding@aasm.org.