Header: This week, HHS issued a guidance letter on how Medicare Advantage plans can make coverage decisions. One aspect of the letter is "AI," but there are also general rules. Anyone working in Medicare reimbursement will want to review all 14 pages.
See also a Hill hearing on AI and Medicare Advantage.
CMS issued guidance to Medicare Advantage programs on how they can make claims-processing and policy coverage decision. While this garnered some headlines due to the paragraphs around uses of AI in Denials, it's also a broader document that cites to regulations created about a year ago.
- See 42 CFR 422.101.
- Guidance https://cdn.arstechnica.net/wp-content/uploads/2024/02/cms-memo-2624-faqs-related-to-coverage-criteria-and-utilization-management-requirements-in-cms-final-rule-cms-4201-f.pdf
- News article. https://arstechnica.com/science/2024/02/ai-cannot-be-used-to-deny-health-care-coverage-feds-clarify-to-insurers/
- News articles at STAT (2023, 2024):
- See John Warren's essay on the CMS letter, here.
- CMS is also running a Medicare Advantage request for information, active to May 24, 2024, here. CMS had previously run an RFI on MA in 2022.
Some of this used to be program manual text (and may still be), and the policy was "upgraded" to the force of a regulation last year.
Here is a GPT4 summary and 10 takeaways.
- Align with Traditional Medicare: MA plans must ensure their coverage criteria align with those of Traditional Medicare, particularly regarding medical necessity determinations.
- Transparency in Coverage Criteria: Plans are required to make their internal coverage criteria publicly accessible, ensuring transparency.
- Prior Authorization Reforms: The memo emphasizes the need for MA plans to streamline prior authorization processes to reduce delays in patient care.
- Utilization Management Oversight: MA plans must annually review their utilization management tools, including algorithms and AI, to ensure they are evidence-based and not discriminatorily applied.
- Non-Discrimination in Coverage Decisions: Plans must avoid using discriminatory practices in coverage decisions, ensuring equal access to necessary care for all beneficiaries.
- Evidence-Based Decision Making: Coverage determinations should be based on the latest clinical evidence and guidelines.
- Public Accessibility of Information: MA plans must provide easy access to information about coverage determinations and available appeals processes.
- Annual Reporting Requirements: Plans are required to report their utilization management practices and outcomes to CMS, promoting accountability.
- Impact on Supplemental Benefits: The memo clarifies how the new rules affect supplemental benefits, ensuring they complement but do not replace mandatory benefits.
- Enforcement and Compliance: MA plans must be prepared for CMS oversight and enforcement of these new rules to ensure compliance.