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AHA Says Medicare Advantage Plans Aren’t Adhering to 2024 Rules

By December 8, 2023No Comments

The American Hospital Association is pushing Medicare to make sure that Medicare Advantage (MA) plans adhere to federal rules for calendar year 2024, sending a letter to the Centers for Medicare & Medicaid Services (CMS) highlighting certain MA plan policies that AHA believes run afoul of the rules.

AHA’s Nov. 20 letter to CMS followed up on a previous letter in which it urged “rigorous oversight” from CMS on the calendar year 2024 final rule, and had expressed concerns about reports from AHA members about certain Medicare Advantage organizations who had no intention of changing their utilization management programs to account for the new rule.

During public comment on the rule last year, THA supported CMS’s proposals for the 2024 rule and provided examples of harm to patients in Texas from MA plans’ misuse and overuse of utilization management practices.

“In other cases, it appears some plans are making changes to the terminology they use in denial letters that may be intended to circumvent recent CMS rulemaking,” AHA wrote in the Nov. 20 letter. “Indeed, one plan recently issued guidance to its network providers indicating that they plan to continue using internal criteria beyond the Traditional Medicare criteria to evaluate inpatient admissions. We believe this circumvents CMS’ rules regarding the use of more restrictive coverage criteria and the requirement that plans adhere to certain public accessibility and evidentiary standards.”

AHA is concerned those health-plan practices “will result in the maintenance of the status quo where [Medicare Advantage organizations] apply their own coverage criteria that is more restrictive than Traditional Medicare proliferating the very behavior that CMS sought to address in the final rule, resulting in inappropriate denials of medically necessary care and disparities in coverage between beneficiaries in MA and those in the Traditional Medicare program.”

The letter urges CMS to take several actions, including clarifying that “the flexibility for MA plans to supplement Traditional Medicare rules with additional internal coverage criteria is not applicable for medical necessity reviews of inpatient admissions and level of care decisions and should only be used in certain limited circumstances.”

AHA recently released a guide for member hospitals to help them “understand and hold Medicare Advantage plans accountable for policy changes” that take effect under the new rule in January. (Anna Stelter/Matt Turner)