LeadingAge’s Medicare Advantage (MA) advocacy efforts are paying off with new tools and resources from the Centers for Medicare and Medicaid Services (CMS). Listed below, each can be used by providers in discussions with plans by establishing the CMS expectations of plans related to coverage determinations, prior authorizations, interrupted stays, plans’ use of artificial intelligence and algorithmic tools (e.g., NaviHealth), and other issues. We’ve also created a how-to document for guidance on reporting when MA plans aren’t complying with the new rules or Medicare regulations. These reports will help the agency identify areas where additional guidance, regulation or law changes are needed in the MA program.

• CMS Memo Clarifying Grounds for Termination: Members can use this when MA plans seek to terminate coverage because a beneficiary fails to progress or lack of improvement. See CMS’ February 13 memo sent to Medicare Advantage organizations (MAOs); read more in this article: CMS: MA Plans Can’t Terminate Skilled Care Because Beneficiaries Don’t Improve.
• CMS Frequently Asked Questions on CY20204 MA Regulations: This memo clarifies MA plans’ compliance requirements on key issues, including interrupted stays and the use of algorithms or artificial intelligence tools. For members, this resource is a useful reference to better understand what plans can and cannot do beginning January 1, 2024, when the CY2024 MA rules went into effect. The FAQs, which respond to a November 29 2023 request from LeadingAge and other Post-Acute Care (PAC) Coalition partners, can be accessed here.

While the above tools—and the advocacy that led to their creation—are a step in the right direction, more must be done to ensure beneficiaries can get the care and services they need (and are afforded under Medicare terms). That’s why LeadingAge created this how-to document to explain what MA non-compliance issues to report on and the information to include. These reports will help LeadingAge advocate to CMS for further clarifications and seek action in correcting the non-compliant practices.

For more information, read See Something, Say Something on MA Plan Compliance, and follow the latest in our Improving Medicare Advantage serial post.