2024 Medicare Advantage, Part D Final Rule Addresses Prior Authorization, Equity and Affordability

April 11, 2023

On April 5, 2023, the Centers for Medicare & Medicaid Services (CMS) released the 2024 Medicare Advantage and Part D Final Rule, which will revise regulations governing Medicare Advantage (MA), the Medicare Prescription Drug Benefit (Part D), Medicare cost plans, and Programs of All-Inclusive Care for the Elderly (PACE). The rule makes changes related to prior authorization, health equity, marketing and communications, and other areas on which Association for Clinical Oncology (ASCO) commented during the rulemaking process.

Prior Authorization

CMS finalized the following changes to prior authorization requirements in MA in response to concerns from ASCO, the Office of the Inspector General, and other stakeholders that prior authorization processes are limiting beneficiary access to care. Beginning January 1, 2024, MA plans will be required to:

  • Follow Traditional Medicare coverage guidelines when making medical necessity determinations, including national coverage determinations (NCDs), local coverage determinations (LCDs), statutes, and regulations.
  • Establish internal coverage guidelines, in the absence of coverage guidelines noted above, based on widely used guidelines and clinical literature. This information must be made publicly available.
  • Make a prior authorization approval valid for as long as medically necessary to avoid disruptions in care and in accordance with applicable coverage criteria, the patient’s medical history, and the treating provider’s recommendation.
  • Provide a minimum 90-day transition period when an enrollee who is currently undergoing treatment switches to a new MA plan, switches from traditional Medicare to an MA plan, or is new to Medicare.
  • Establish a committee that reviews utilization management and prior authorization policies annually and keeps current of LCDs, NCDs, and other Traditional Medicare coverage policies.

CMS also finalized a policy that coverage determinations must be reviewed by professionals with relevant medical expertise before a plan may deny coverage. While ASCO supports a review prior to a denial of a prior authorization request, the Association is concerned that the physician or other appropriate health care professional reviewing the request does not need to be of the same specialty or subspecialty as the treating health care provider. ASCO will continue to advocate for policies that ensure the treating oncologists have direct access to an oncologist employed or authorized by the payer to make prior authorization determinations in cancer care.

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 will also 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.

Low digital health literacy is one of the most significant obstacles in achieving telehealth equity. To address this, MA organizations will be required to develop and maintain procedures to identify individuals with low digital health literacy and offer them digital health education to help them access telehealth benefits.

Marketing and Communications

CMS has finalized 20 of 21 proposed changes aimed at eliminating confusing and potentially misleading marketing practices among MA plans. CMS will prohibit ads that do not mention a specific plan name and those that incorporate words, imagery, Medicare logos, and other language that may confuse or mislead beneficiaries or misrepresent the plan. CMS also finalized changes aimed at preventing predatory behavior and that strengthen the role of plans in monitoring agent and broker activity. Additionally, CMS is finalizing policy aimed at helping enrollees receive accurate information about Medicare coverage and to educate them on accessing accurate information from other relevant sources.

Inflation Reduction Act and Consolidated Appropriations Act, 2021 Implementation

The rule expands eligibility for the full low-income subsidy benefit to individuals with incomes up to 150% of the federal poverty level who meet eligibility criteria, beginning January 1, 2024. 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.

Read ASCO’s comments on the proposed Medicare Advantage and Part D rule.

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