On  January 27, LeadingAge submitted its comment letter to the Center for Medicare and Medicaid Services (CMS) on the proposed CY2026 Medicare Advantage, Part D and Programs of All-Inclusive Care for the Elderly (PACE) policy and technical rule.  As noted in the LeadingAge summary of the rule’s key components, the far-ranging 700+ page rule covers PACE, supplemental benefit flex cards, prior authorizations, artificial intelligence guardrails, dual eligible integration policies, vertical integration and medical loss ratios, which could impact members’ contracts with health plans.

Our letter offered our support for many of the proposals that are designed to improve beneficiary access to traditional Medicare A and B benefits by constraining plans’ use of internal coverage criteria and artificial intelligence and also seek to ensure beneficiaries access to the promised MA plan supplemental benefits.

We argued for CMS to include skilled nursing facilities and home health agencies in all of its proposed changes to MA plan organization determinations, their appealability and corresponding payment protections, as some of these proposals were restricted to inpatient hospitals.

LeadingAge suggested CMS expand its proposed list of information that Medicare Advantage (MA) brokers and agents are required to communicate to Medicare beneficiaries to also require them to inform Medicare beneficiaries that enrolling in an MA/SNP plan and using certain supplemental benefits could jeopardize their other government assistance.

We also presented some additional considerations to CMS’s proposed Medical Loss Ratio (MLR) changes and vertical integration request for information. The MLR changes could dampen MA plans’ interest in entering into certain types of alternative payment arrangements with providers unless they are directly tied to clinical outcomes, and future policies to restrain vertical integration could have negative consequences for current provider-led MA/SNP plans.

Finally, we made recommendations related to the PACE proposals regarding encounter data submissions and pointed out the costs of the proposed technical changes to the nondiscrimination requirements.  Members are reminded, this proposed rule originated in the Biden Administration and the Trump Administration will decide whether to finalize it in whole, in part or not at all.  These decisions on a final rule are expected by early April 2025.