Thursday, December 15, 2022

Brief Blog: New Medicare Advantage Regs; Focus on New Coverage Rules & Misleading Advertising,

CMS has released proposed rules for Medicare Advantage (& Part D).  The rules cover numerous topics but the headline focus from CMS has been on "misleading advertising" in Medicare Advantage plans.

Note that there are also many pages, and new regulations, on how Med Adv plans must implement LCD coverage, other coverage, and clinical trial coverage (notes at bottom of blog).


The term "misleading" occurs 28 times in the proposed rule and 4 times in the Fact Sheet. (The term "fraud" occurs 34 times).

Note that, separately, CMS has proposed regulations that would affect prior authorization and require electronic submission and adjucation in Medicare Advantage, Medicaid, and Exchange Plans (here).   Congress had also proposed some statutory changes around Prior Auth, but only focused on Medicare Advantage. 

As usual, CMS issues three documents, a press release, a fact sheet, and the actual rule.   The typeset publication will be 12/27 in Federal Register.  Comment to February 13.  

The rule doesn't occur in isolation.  

  • CMS notes that a "request for information" last summer drew 4000 comments.
  • In October, 2022, CMS vowed to crack down on misleading M.A. marketing.  Here
  • The Senate recently looked at misleading M.A. marketing.  Here.
  • Initial press coverage Dec 14 from AP and from Fierce Healthcare.
    • The latter covers both the prior auth rule (12/7) and the misleading marketing rule (12/14).


CMS promises to clarify regulations for M.A. plans regarding clinical trials; see  rule preprint p 390ff and section G / Regulation 422.101, 422.109.  

See also discussion of Med Adv having "basic coverage" such as by reference to LCDs at page 130ff.   This is a basic idea in Medicare, but it is being beefed up by rulemaking and provides stakeholders a good change to comment.  (Also related are rules about utilization management and prior auth, p. 148ff).