CMS Enhances Medicare Advantage Beneficiary Protections

The Centers for Medicare & Medicaid Services (CMS) announced significant enhancements to beneficiary protections within the Medicare Advantage (MA) program, as outlined in the Contract Year (CY) 2025 Medicare Advantage and Part D Final Rule. The final rule encompasses revisions to policies governing various aspects of Medicare Advantage, Part D, Medicare Cost Plans and the Program for All-Inclusive Care for the Elderly (PACE).

Several specific policies were successfully advocated for in the final rule. These policies aim to ensure individuals enrolled in MA plans have access to high-quality care and timely, medically necessary services. Highlights include:

• Right to Fast-Track Appeals: Beneficiaries now have the right to fast-track appeals by Quality Improvement Organizations for terminated non-hospital services, regardless of timeliness or beneficiary status.
• Network Adequacy Exception Request for Facility-based I-SNPs: This provision is expected to alleviate network adequacy challenges faced by smaller plans. CMS acknowledges distinct care use patterns for beneficiaries residing in skilled nursing facilities for 90 days or more. It introduces a new exception process for facility-based I-SNPs on a single contract ID under specific conditions.

Additionally, CMS finalized several other proposals, including:

• Advancements in Medicare-Medicaid integration.
• Expanded access to behavioral health services.
• Increased transparency regarding supplemental benefits.
• Mid-year notification for enrollees regarding unused supplemental benefits.
• Guidelines on agent/broker compensation.
• Strengthening of health equity requirements on MA use management committees.

These regulations will apply to coverage starting January 1, 2025, with some exceptions.

CMS also reminds stakeholders of its request for information on MA data, with the comment period closing May 29, 2024. AHCA/NCAL will submit comments. This final rule follows the release of the CY 2025 Medicare Advantage Rate Announcement, estimating an average 3.7% increase ($16 billion) in MA plan revenues alongside reduced MA benchmark rates. For more information, see the CMS fact sheet and the full final rule in the Federal Register.