The Centers for Medicare and Medicaid Services (CMS) recently issued 2024 Medicare Advantage(MA) and Part D audit report, which examines plan compliance with MA regulations, finds MA enrollees still faced delayed care in 2024 due to failures in MA plan internal processes.

Early in 2024, CMS committed to LeadingAge and our Post Acute Care (PAC) Coalition that they would hold plans accountable to comply with the revised MA regulations that took effect January 1, 2024, especially around utilization management practices like prior authorization.  The audit report highlights that plans still have work to do to shore up their internal processes and systems to ensure timely and accurate coverage decisions are being made and that enrollees and providers have the information they need to appeal adverse decisions.

CMS stresses, “This report is not intended to reflect overall industry performance and should not be interpreted to mean that there are pervasive issues throughout the industry related to the noncompliance” that the agency identified.

CMS audited 494 MA contracts in 2024 covering 87.6% of all beneficiaries enrolled in an MA plan. This would suggest that CMS looked at data from many of the large national plans, and the bulk of plans overall.

What is less clear from the report is how many MA enrollees were impacted by the noncompliance issues identified. The report did not indicate the proportion of plans that were noncompliant with the identified items.

While the report’s findings are not surprising based upon what LeadingAge hears regularly from LeadingAge members, it is most disappointing that delays in plan coverage decisions persist, that plan reviewers continue to miss “pertinent clinical information when processing coverage requests that indicated services should be approved” and that errors in plan systems create wrongful denials of coverage.

One of the benefits of the report, however, is that it keeps these issues in the spotlight for correction and it reinforces what we’ve been telling CMS is happening in the field.

LeadingAge, along with its PAC Coalition partners, will continue to push for enforcement of the MA regulations to ensure beneficiaries can receive the timely access to care and services they deserve.  The complete 2024 MA audit report can be accessed here.