The Centers for Medicare & Medicaid Services (CMS) released a proposed rule on Nov. 26, 2024, introducing changes to multiple Medicare programs including Medicare Advantage (MA). This proposal strengthens accountability measures for MA and Part D plans to ensure beneficiaries receive timely, appropriate care. Key provisions include new restrictions on prior authorization practices, guidelines for artificial intelligence (AI) implementation in health care decisions, and improving provider directory accuracy. The overall rule seeks to enhance access to behavioral health services.
Some of the key provisions include:
Strengthening Prior Authorization and Utilization Management Guardrails
Stakeholders have increasingly demanded reform of MA plans' prior authorization, utilization management, and coverage determination processes. A key concern for CMS is the significant burden these processes place on health care and mental health providers. To address these issues, CMS is implementing stronger oversight measures to curb excessive prior authorization requirements. New proposals focus on several key areas: establishing clear definitions for internal coverage criteria, requiring greater transparency in plan policies, strengthening beneficiary appeals rights, and addressing payment implications of reversed decisions.
Ensuring Equitable Access to Behavioral Health Benefits Through Cost Plan and MA Cost-Sharing Limits
To enhance behavioral health care accessibility, CMS is aligning MA and Section 1876 cost plans' in-network cost sharing with Traditional Medicare rates. This alignment aims to balance affordability with maintaining stable access to care. The proposed cost-sharing structure includes key changes including mental health specialty care, psychiatric services, partial hospitalization/intensive outpatient care, and outpatient substance abuse treatment that will require only a 20% coinsurance or equivalent copayment, reduced from the current 30%–50% range. These changes are particularly significant because they represent one of the largest expansions of behavioral health access in MA history.
Formatting Provider Directories for the Medicare Plan Finder (MPF)
The Medicare Plan Finder serves as a central online platform for beneficiaries to compare MA and Part D plans, offering details about benefits, costs, and quality ratings. Currently, provider network information is only available through separate MA plan websites as downloadable directories or searchable databases, requiring beneficiaries to navigate multiple sources. To streamline this process, CMS proposes integrating provider directory data directly into the MPF. Under this proposal, MA organizations would be required to submit provider directory data to CMS for MPF integration and verify the accuracy of their provider information. This integration aims to create a more user-friendly, comprehensive comparison tool for Medicare beneficiaries.
Creating Guardrails for Artificial Intelligence (AI)
To prevent discriminatory outcomes, CMS is establishing requirements for MA plans to deliver equitable services regardless of whether decisions are made by human staff or AI systems. The new guidelines specifically mandate that AI and automated systems used by MA plans must adhere to existing regulations, ensure fair access to services, and eliminate discrimination based on health status factors. These requirements aim to harness AI’s potential while safeguarding person-centered care and equal treatment for all beneficiaries.
NBCC will provide comments to CMS supporting the key provisions highlighted in this post.
