Monday, April 10, 2023

Brief Blog: Medicare Advantage Must Cover "Traditional Medicare's" Benefits; Enhanced Rules

You may have seen articles, like this one at STAT, that based on brand-new federal rulemaking, Medicare Advantage plans must cover fee-for-service ("traditional Medicare") benefits.  As defined in NCDs and LCDs.

You may have wondered, what's new?  That has been the rule for years, and even enshrined in a regulation as well as the policy manuals (e.g. managed care Chapter 4 section 10.16).  However, CMS states that denials still occur, such as repetitive pre-auth denials for covered services, or denials not appealed when physicians don't understand their rights or the rules.

The short answer, CMS seems to be beefing up its regulations (such as 42 CFR 422.101).  See the early release typescript of the Medicare Advantage rule; from page 205 forward (205-251, but then followed by prior auth rules which are also of interest).   

Find the new rule here (p 205 fwd):

See April 12  Fed Reg for the final typeset rule.

The rulemaking goes on many pages, but includes a comment that MA plans must use current evidence in "widely used treatment guidelines."  Much of the new text (inserted at 42 CFR 422) has to do with processes for MA plans making coverage documents that apply outside of NCD and LCD rules.

There is a discussion of NCD/LCD processes (page 239).  There is a remark that an existing regulatory statement about complying with Medicare manuals is deleted.   This is important, because some types of coverage are found only in manuals.  CMS states, somewhat vaguely, that Medicare manual compliance remains required - so it is pretty fuzzy why go to the trouble to delete this phrase from regulations.  

CMS multiple times cites an OIG report in April 2022 on MA plans and denials -