In an August 21 meeting with the Centers for Medicare & Medicaid Services (CMS), LeadingAge learned that CMS is drafting subregulatory guidance that would provide further clarifications to the recent Medicare Advantage rules that largely take effect January 1, 2024. It seems the guidance will provide more specifics about which Medicare coverage regulations and guidance plans must follow, and in what cases plans can deviate with their own internal criteria.

CMS is also examining how plans are using third-party algorithms or tools to determine the amount of care a person receives from a given provider. Subregulatory guidance might clarify what steps a plan must take if they are planning to terminate service based upon the output of such a tool. For example, would the plan need to identify what coverage criteria is no longer being met, resulting in service termination? Would the plan need to conduct another assessment of the person’s current condition?  LeadingAge has been discussing these issues and others with other post-acute care associations to provide additional input into the CMS process.

Members are encouraged to submit examples of non-compliance issues to Nicole Fallon (nfallon@leadingage.org). What was the specific scenario where an MA plan made a decision that appeared not to comply with Medicare coverage criteria? What type of regulation, memo, etc., did the plan not follow (e.g., person showed lack of progress in rehabilitation but still had a feeding tube)?  Were there situations where a plan has stuck with the third-party care manager’s (e.g. NaviHealth, Care Centrix, MyNexxus) algorithm even though assessments or other information would suggest the person still has a skilled need? This information will be shared with CMS in aggregate to help guide the clarifications included in its subregulatory guidance.