The Center for Medicare and Medicaid Services (CMS) finalized its 2025 Medicare Advantage and Part D policy rule on April 4, 2024. The final rule, which will be published in the Federal Register on April 23, includes provisions enhancing MA enrollees’ right to appeal coverage terminations to a Quality Improvement Organization (QIO) even in cases where the appeal request is untimely or the person is no longer in a SNF or receiving home health services. This creates parity to the rights available in traditional Medicare. CMS appears to have largely finalized what it proposed (see our comments here) with some revisions. The final rule also includes a special exception to network adequacy requirements for facility-based institutional special needs plans, requires plans to review their prior authorization policies and procedures to ensure they don’t impose unnecessary barriers to care for certain populations; and seeks increased greater plan transparency and accountability for the supplemental benefits that plans offer to beneficiaries ensuring they are clear on which benefits are available to them and how to access them. LeadingAge staff are reviewing the final rule in its entirety and will provide a more detailed analysis soon.

Although under pressure from Medicare Advantage (MA) plans and some Congressional members to pay MA plans more in 2025, CMS finalized MA plan 2025 rates on April 1 at its proposed 3.7% level based upon more complete data on utilization and growth rate. MA plans have expressed concerns that the increase does not reflect current utilization, inflation, and risk score growth; and as such, they argued it resulted in a cut of 0.16% because health risk scores have increased more than the rate increase to 3.86%.

“Medicare Advantage beneficiaries deserve to receive the care they need, and providers, who deliver it, deserve to be paid for services they deliver in a financially sustainable way,” stated Katie Smith Sloan in an April 1 press release.

The final payment announcement and rate accounts for growth in Medicare FFS costs health risk scores and incorporates utilization data from the fourth quarter of 2023, which does not show higher utilization patterns than anticipated. The final rate reflects an average expected increase across plan though there will be variation in the specific amounts plans receive based upon a variety of plan-specific factors. Therefore, some plans will receive more and others less in 2025 than 3.7%. CMS does not expect beneficiary premiums or benefits to be negatively impacted by these changes.

The Office of the Inspector General (OIG) – Office of Evaluation and Inspections is exploring issues related to Medicare Advantage (MA) prior authorization denials in Post-Acute Care (PAC) settings. On March 28, LeadingAge shared examples and trends in MA prior authorization denials, administrative burden and payment issues with OIG staff.  When asked if we had seen any changes in plan practices since the CY2024 MA Policy and Technical Rule was implemented on January 1, 2024, we told them that “regrettably our members have seen no change, it appears to be business as usual.”  We noted, based upon our members’ reports, we have observed a broad lack of understanding by the MA plans of what Medicare covers as skilled care in both Skilled Nursing Facilities and Home Health agencies. OIG also asked if members were observing MA plans terminate care early and whether this was a concern. We provided examples from members about terminations where clinical and therapy staff disagree with the plan determination, what appears to be a lack of accountability by plans for safe discharges, and frequent terminations for situations that are clearly skilled care. We also shared a specific case from February 2024, where a SNF resident on three times a day IV therapy was told it was time to go home even though 3 weeks remained on their treatment course. Fortunately, we were able to correct this situation by reaching out directly to CMS staff when regular channels prevented action. We also described an increasing trend in MA plans refusing to approve SNF care for long-stay nursing home residents stating that “they can get their needs met in the long term care;” representing further evidence of a lack of understanding of the differences between custodial care, skilled care and therapy services. OIG staff expressed appreciation for the real-world examples that highlight the additional administrative burden providers face and how delays, denials and early terminations of care all disrupt a beneficiary’s ability to get the timely care they need. OIG has met with other PAC provider groups for input. They said there is currently no set timeline for producing a report, but they are hopeful one will be added to their work plan. OIG staff encouraged us to continue to share additional items that we learn from members and any data we collect on prior authorizations.

The Office of the Inspector General (OIG) issued what it is calling a first impact brief on what impact the OIG’s work is having on Medicare Advantage (MA) prior authorizations. Regrettably, LeadingAge is not seeing the same results OIG outlines in its brief. LeadingAge provider members are not observing a marked decline in prior authorizations or inappropriate care denials as a result of the Calendar year 2024 MA policy rules on prior authorizations covering a “course of treatment.” Instead, it appears to be business as usual. While the OIG brief states that UnitedHealth, Cigna and Aetna have reduced the number services requiring prior authorization by up to 20%, these are not services in the post-acute care space. The good news is LeadingAge staff will be meeting with OIG next week, March 28, to share what our members are seeing and their concerns with the MA plan processes related to prior authorizations including early discharges from post-acute care.  Members who wish to share particular experiences can email Nicole Fallon with examples of recent prior authorization issues.

LeadingAge Massachusetts members were part of a March 4 roundtable of health care providers hosted in Boston by Sen. Elizabeth Warren (D-MA) and CMS Administrator Chiquita Brooks-LaSure to discuss provider difficulties with Medicare Advantage (MA) plans.

The three LeadingAge provider members in attendance described the negative effects of prior authorization decisions that are delayed and/or terminated early by MA plans, thus reducing provision of needed services to older adults or sending them home prematurely. Hospital representatives likewise described the effect of these delays on their end—preventing discharge of patients to post-acute settings, thus backing up the movement and rehabilitation of other emergency room patients.

The hosts and attendees also discussed use of artificial intelligence algorithms to deny care and deceptive marketing and upcoding practices, along with recommendations from the providers.

Read the full LeadingAge article for more details.

LeadingAge submitted its feedback on the Centers for Medicare & Medicaid Services (CMS) CY2025 Medicare Advantage (MA) Advance Payment Notice on March 1. CMS issued the Advance Payment Notice—describing the MA payment policies for the upcoming plan year—on January 31, 2024, and will issue the final rate announcement on or before April 1, 2024.

CMS proposed to increase MA plan payments in CY2025 by 3.7% but MA plans view it as a -0.16% cut, saying it does not account for the growth in patient risk scores. LeadingAge took this comment opportunity to raise an alarm that MA plans are currently underpaying skilled nursing facilities and home health providers, while at the same time overburdening them with administrative tasks—prior authorizations, appeals, and payment clawbacks.

We also suggested that CMS look at restructuring the MA plans quality bonus program to be more like quality and value-based payment programs applied to provider payments. The quality bonus program adds to MA plans’ base per member per month payments in comparison to provider quality-related programs that deduct from provider payments and require them to earn it back. If CMS were to restructure, it could return funds to the Medicare Trust Fund, thereby bolstering its solvency.

LeadingAge supports members with strong advocacy for improving Medicare Advantage (MA)—and our efforts are paying off with new tools and resources from the Centers for Medicare and Medicaid Services (CMS). Access these resources more from LeadingAge to help identify areas where additional guidance, regulation, or law changes are needed in the MA program.

The Encounter Data Enhancement Act, S. 3307, would require Medicare Advantage (MA) plans to report more data elements for each item or service provided to a MA enrollee beginning January 1, 2026. One such data point is requiring the plans to indicate the type of payment they make to the provider—capitated, value-based or fee-for-service, and the amount allowed for each item or service. The legislation would also require plans to report when in-home health risk assessments(HRAs) are completed and the entity completing it.

MA plans have been under scrutiny for conducting in-home HRAs that lead to higher beneficiary risk scores and in turn, ensure higher payments to the plans for these beneficiaries. This bill covers one aspect of MA transparency that LeadingAge would like to see adopted. The bill is sponsored by Sens. Catherine Cortez Masto (D-NV), Bill Cassidy (R-LA), Elizabeth Warren (D-MA), and Marsha Blackburn (R-TN). LeadingAge will provide additional suggestions on MA data transparency in its response to a CMS MA Data Request For Information expected to be submitted in May following broad input from members via our member networks.

LeadingAge Nebraska president and CEO Kierstin Reed testified on February 23 at a Senate Aging Committee field hearing, “Medicare & Medicare Advantage: Challenges and Opportunities with Enrollment,” on the complexities of the Medicare enrollment process and the confusion many beneficiaries face when they are denied coverage for post-acute and long-term care services, particularly in the Medicare Advantage (MA) space. The hearing was held in Omaha, Nebraska, by Senator Pete Ricketts (R-NE), whose family’s personal experience served as part of the hearing’s inspiration.

Read more in the full LeadingAge article.

Change Healthcare, a subsidiary of UnitedHealth Group since 2022 and its Optum Solutions division, is a payment exchange platform used broadly by health care providers and was the victim of a cyberattack on February 21. Optum reports that once the attack was identified it disconnected the Change Healthcare platform from its other systems thereby containing the threat.

“This action was taken so our customers and partners do not need to [disconnect],” said Optum. “We have a high level of confidence that Optum, United Healthcare, and UnitedHealth Group systems have not been affected by this issue.”

More details are available in this LeadingAge article.

The Centers for Medicare and Medicaid Services (CMS) announced updates to instructions and systems changes to facilitate the submission of data on supplemental benefits in the Medicare Advantage (MA) Encounter Data System (EDS) on February 21. All plans and PACE organizations can and therefore must submit data on supplemental benefits, according to CMS updates. Read more.

As the Centers for Medicare and Medicaid Services (CMS) and the Center for Medicare and Medicaid Innovation (CMMI) explore the  hospice Value-Based Insurance Design Model (VBID), LeadingAge submitted comments and joined with numerous other organizations (the American Academy of Hospice and Palliative Medicine, National Association for Home Care and Hospice, National Coalition for Hospice and Palliative Care, National Hospice and Palliative Care Organization, National Partnership for Healthcare and Hospice Innovation, and the Physician Associates in Hospice & Palliative Medicine) in sending a February 16 hospice community letter urging CMS not to allow Medicare Advantage (MA) organizations to limit beneficiary access to in-network providers without sufficient guardrails in place to minimize any disruptions in care and to not move forward with hospice prior authorization at this time.

In a win for LeadingAge members, the Centers for Medicare and Medicaid Services (CMS) has clarified policy on Medicare Advantage (MA) plan coverage terminations, following a request from LeadingAge and its MA advocacy coalition partners.

In a February 13 CMS memo to Medicare Advantage organizations, the agency emphasized that MA plans must follow Medicare regulations related to the Jimmo Settlement Agreement (2013), and reminded them to  “refresh and/or train staff and contracted providers” on this policy, “which clarified that the Medicare program covers skilled nursing care and skilled therapy services under Medicare’s skilled nursing facility, home health, and outpatient therapy benefits when a beneficiary needs skilled care in order to maintain function or to prevent or slow decline or deterioration …”

CMS noted that there may be a misconception that the Medicare program only covers nursing and therapy services under Medicare when a beneficiary is expected to improve. For more on the CMS memo and the steps MA plans must take to comply, see the full article.

LeadingAge and our Post-Acute Care (PAC) Coalition partners, which includes the Center for Medicare Advocacy, asked the Centers for Medicare & Medicaid Services (CMS) for further clarification on how the CY 2024 Medicare Advantage (MA) rules on coverage determinations and prior authorizations would apply in PAC settings. In response, CMS issued Frequently Asked Questions (FAQs) on February 6 addressing several of the issues we raised—an advocacy win for PAC providers. The two key issues:

• Interrupted stays: Plans cannot require a second prior authorization for an interrupted stay.
• MA Plan Use of Algorithms or Artificial Intelligence (AI) tools: In this case, CMS is limiting plans’ use of algorithms and AI to a guide that must be refined by the patient’s individual circumstances that must dictate whether services are still needed. CMS includes a PAC example noting that these tools cannot be used to terminate PAC services noting a reassessment must be completed to determine if the person no longer meets level of care requirements. This should push plans to now consider changes in condition in their determinations.

Providers are encouraged to use the FAQs in discussions with MA plans.

Now that Medicare Advantage (MA) annual enrollment is behind us, we have our first glimpse at the 2024 MA program. We see MA is here to stay but the numbers have reached a level where the program can no longer be ignored by policymakers. Here are some quick stats about MA in 2024:

• 32.8 million Medicare beneficiaries were enrolled in MA as of the January report of MA State/County Penetration. This is an increase from 30.9 million enrolled in MA in 2023 and continues the recent trend of roughly two million more lives enrolling in MA plans each year.
• There are 5,786 MA plans being offered in 2024 and the average beneficiary has access to 43 plans, many of which are $0 premium plans. While the majority of these plans are HMOs (56%) in structure (which typically means a more limited network), the percentage that are PPOs has been increasing. PPOs allow beneficiaries to select care from in-network and out-of-network providers though their out of pocket costs are higher outside the network.
• 2,334 of the MA plans offer non-medical supplemental benefits in 2024, which is a slight increase over 2023 (2,268 plans) and might indicate a slowing of enthusiasm by plans.
• In-home services continue to lead the list of these primarily health-related benefits offered by 867 MA plans in 2024 but this represents a significant decline from the 1,308 plans offering this benefit the year prior.
• The food and produce benefit tops the list of Special Supplemental Benefits for the Chronically Ill  offered by 1,475 plans and “general supports for living” comes in second, available through 996 plans. Overall, it only matters if these benefits are available in your geography. The ATI Advisory report cited below has more detail on where supplemental benefits are being offered.

Sources: ATI Advisory “Nonmedical Supplemental Benefits in medicare Advantage in 2024” and KFF’s “Medicare Advantage 2024 Spotlight: First Look” and the CMS January 2024 MA State/County Penetration data.

As part of its annual payment notice, CMS proposes to update Medicare Advantage (MA) plan rates by an average of 3.7% for CY 2025, which roughly what they receive in most years. Not all agree that this is a rate increase. Some describe it as a cut. For more background on the CMS CY 2025 Advance Notice for the Medicare Advantage and Part D programs (CMS-0006-P), click here.

Two letters were sent to the Centers for Medicare & Medicaid Services (CMS) Administrator, Chiquita Brooks-LaSure, last week with distinctly different messages about what actions CMS should take with regard to the Medicare Advantage (MA) program.

Read the full LeadingAge article and if your Senator is on the list, this is an opportunity to reach out and share your concerns on how plan payments to providers and the administrative burdens of prior authorizations and payment clawbacks also put the MA program at risk.

Read the full LeadingAge article on how things are heating up on Medicare Advantage (MA) at the latest Medicare Payment Advisory Commission (MedPAC) meeting. The January 12 meeting focused on a report providing a status update on the MA program.

On January 25, the Biden-Harris Administration launched efforts to increase Medicare Advantage (MA) transparency in order to increase competition. The Centers for Medicare and Medicaid Services (CMS) has already begun collecting more data related to various aspects of MA, including more comprehensive payment data related to Medical Loss Ratios (MLRs), new data streams for supplemental benefits costs and utilization, new data collection and public posting requirements related to prior authorization, and new collection of race and ethnicity data.

CMS has also increased requirements for the completeness of encounter data.  This newly released request for information (RFI) seeks input from the public regarding various aspects of MA data including access to care, prior authorization, provider directories, and networks; supplemental benefits; marketing; care quality and outcomes; value-based care arrangements and equity; and healthy competition in the market, including the effects of vertical integration and how that affects payment.

CMS is also seeking comments on improving MA data collection and release methods. The RFI has an extended comment period of 120 days to encourage feedback from a wider array of stakeholders and to allow time for convenings and other efforts to synthesize detailed feedback to CMS.

Comments are due on May 29, 2024, and we will be engaging members through various networks to gain insights and feedback for our comments.

Leaders of the Centers for Medicare & Medicaid Services (CMS) told LeadingAge and coalition partners from other post-acute care associations and the Center for Medicare Advocacy on January 3 that it will be robustly enforcing the new CY2024 Medicare Advantage (MA) policy and technical rules that took effect January 1, 2024, and staff welcome our support in reporting issues of non-compliance with the rules.

Read the full LeadingAge article for more details on our meeting with CMS leaders who oversee the MA program.

LeadingAge submitted comments on the CY 2025 Medicare Advantage (MA) proposed policy and technical rule on January 5. Its proposals are markedly different from last year, primarily requiring more transparency and actions from MA plans and fewer changes with direct impacts on providers.

Read the full LeadingAge article for more details.

New Medicare Advantage (MA) rules taking effect January 1, 2024 have the potential to make improvements to the prior authorization process and ensure Medicare beneficiaries receive medically necessary services through their MA plan. Plans have said they don’t see anything in the rules that would make them change current practices.  LeadingAge and other providers will begin collecting incidences of non-compliance with MA and Medicare rules starting January 1 to support CMS enforcement.

Read the full LeadingAge article here.

CMS sent a letter on December 14 to pharmacy benefit managers, Medicare Part C and D plans, Medicaid Managed Care plans and Private Insurers that  they are receiving reports that these plans are “threaten[ing] the sustainability of many pharmacies, imped[ing] access to care and put[ting] increased burden on health care providers.” Much of the focus of the letter is on practices related to pharmacies. Specifically, the letter notes that there have been reports of plans paying pharmacies less than their costs to administer the vaccines, which is impeding access to individuals receiving these vaccines.

However, the final paragraph of the letter focuses on the new regulations related to prior authorizations and coverage determinations that will take effect on January 1, 2024. Many providers have been told by plans that they don’t believe they need to change their practices to comply with the CY2024 MA rules but CMS put plans on notice that they don’t agree with the plans’ interpretation and that “CMS will be conducting robust oversight to ensure Medicare Advantage organizations are complying with these new requirements…”  LeadingAge and its coalition partners will be meeting with CMS MA leaders and staff on January 3, 2024, to learn more about these “robust oversight” measures and how we can help identify situations where plans are failing to comply when the new rules take effect. We also will review our request that CMS issue additional subregulatory guidance that we believe is needed to ensure plan compliance meets the intent of the rules.

LeadingAge applauds the recent bipartisan letter sent to CMS Administrator Chiquita Brooks-LaSure on December 7 from Sens. Elizabeth Warren (D-MA), Catherine Cortez Mastro (D-NV), Bill Cassidy (R-LA), and Marsha Blackburn (R-TN) calling for more transparency in the Medicare Advantage (MA) program. The letter outlined the current shortcomings in MA data collection and reporting efforts and the specific data points that would bring greater transparency to how MA plans handle coverage determinations, prior authorizations, and appeals. In addition, the senators urged CMS to collect more information from plans that will help the policymakers and others assess whether the plans’ processes in these areas result in wrongful denials of care, inequitable access to care for certain populations, and/or MA enrollees choosing to disenroll and why. The senators noted the growing influence of MA in the Medicare program and therefore, the need for better data to understand the effects MA is having on costs, coverage, and quality. LeadingAge has recommended CMS require similar data reporting from MA plans in recent years and we agree that greater transparency can be achieved by collecting more detailed information at the plan level. Check out the letter to see the detailed data requests these senators are requesting.

LeadingAge, as part of a coalition of post-acute care associations and the Center for Medicare Advocacy, wrote a letter asking the Centers for Medicare & Medicaid Services Deputy Administrator and Director of the Center for Medicare, Meena Seshamani, to issue sub-regulatory guidance that clarifies how the final CY2024 Medicare Advantage policy and technical rule applies to post-acute care and what plans must do to comply with the new requirements.

The letter identifies additional information the group believes plans must use in making Medicare coverage determinations (e.g., CMS transmittals and PAC assessments), suggests a prior authorization for a “course of treatment” includes the entire PAC stay with a single authorization, and recommends prohibiting the use of artificial intelligence or algorithmic tools to deny care or override providers’ in-person assessments.

The Centers for Medicare & Medicaid Services (CMS) has issued its annual update to the Medicare Advantage, Special Needs Plan, and PACE programs as part of its CY2025 Medicare Advantage policy and technical proposed rule. The rule was published earlier than usual to the Federal Register on November 15. Comments will be due right after the new year on January 5 at 5 p.m. ET.

The proposed rule contains several beneficiary improvements and continues to strive for greater transparency around plan practices. A couple of notable proposals include enhancing beneficiaries’ right to an independent, fast-track appeal when non-hospital services are terminated by their plan. These appeals would be conducted by an independent review entity such as a Quality Improvement Organization (QIO) even if the appeal request isn’t timely or the person has left the facility. This review is a benefit afforded to Medicare fee-for-service (FFS) beneficiaries but has been limited for those enrolled in an MA or special needs plan (SNP) plan.

The rule also seeks to create additional opportunities for dual-eligibles to enroll an integrated DSNP plans and regular opportunities for institutionalized beneficiaries enrolled in MA plans to change to a different plan or return to Medicare FFS. Both appear to be positives.

Watch for an article soon with a complete analysis.

Members of the Managed Care Solutions Network discussed Medicare Advantage (MA) appeals and various prior authorizations and requests during a meeting on November 16. A few members mentioned they attach a cover sheet with their documentation when submitting prior authorization, re-authorization, and other coverage requests to MA plans. This cover sheets highlights upon which pages the plan reviewer might find critical information for determining medical necessity and in turn, approving covered services.

While these members admitted it is more work for staff, they have found they have greater success in obtaining the initial service approvals for the beneficiary and having denials overturned upon appeal. Other members recommended the importance of building a relationship with the plan case manager as they are quicker to approve additional days of service when there is a change of condition.  Members who are not yet part of this LeadingAge member network can join by emailing Nicole Fallon to be added to the group and its monthly meetings.

The Medicare Payment Advisory Commission (MedPAC) commissioners agreed that a focus on Medicare Advantage (MA) network adequacy and prior authorizations was some of the most important work they could do as MA enrollment now exceeds 51% of the Medicare population.

Read the full LeadingAge article here.

The Better Medicare Alliance (BMA) on October 25 offered seven policy proposals that seek to further “strengthen” the Medicare Advantage program. LeadingAge shared with BMA leaders that many of these proposals align with our own agenda, especially those that  streamline prior authorizations and other utilization management processes. LeadingAge does not oppose any of the BMA proposals, but argues some critical issues are missing. LeadingAge challenged BMA to consider additional proposals to ensure provider payment adequacy and value-based payment opportunities.

The Senate Finance Committee held a hearing on October 18, 2023, about deceptive marketing practices that Medicare Advantage (MA) plans deploy to get Medicare beneficiaries to enroll. The hearing was in follow up to a report issued by the Committee last year that outlined these practices.

Since then, CMS issued new rules for MA plans to follow for the CY2024 MA plan year, including imposing prohibitions on a number of the items identified in the report related to how plans and their third parties market to and communicate with beneficiaries. These changes to marketing and communications practices took effect September 30, 2023, and have resulted in CMS rejecting 300 of 1700 MA ads for being misleading.

As part of the hearing, some states argued for the authority to regulate these “bad actors” and return them for the state level for action because CMS was unable to effectively prohibit these deceptive practices.

This October 18 Senate Finance hearing is one of many recent hearings that have highlighted MA plan bad practices in recent years. It remains to be seen what action Congress will take on the coming weeks or months to address the issues that have been raised by consumers, providers, and regulators.

The Better Medicare Alliance recently updated its state of Medicare Advantage (MA) report for 2023. As of 2023, MA enrollment has reached a tipping point at 51% of all Medicare beneficiaries. The uptake in rural areas is now 40%. It is clear Medicare beneficiaries choose these plans because they cap their out-of-pocket costs (report shows MA enrollees spend 44% less than FFS counterparts) and have low or no cost premiums for plans with additional benefits that Medicare FFS does not provide (e.g., vision, dental, and hearing). According to the report, 52% of MA enrollees have incomes at or below $25,000. United Healthcare and Humana remain the dominant plans in the U.S.

The data reinforces that it is becoming increasingly important for providers to learn how to work with these payers—and equally important that LeadingAge continue to advocate for policies that ensure beneficiary access to Medicare services through these plans and financial sustainability for the providers who deliver those services.

The Centers for Medicare & Medicaid Services (CMS) released details in advance of the CY2024 Medicare Advantage (MA) open enrollment that indicates, on average, MA plan premiums will increase slightly to $18.50 per month (up from $17.86 in 2023) but Part D premiums are shrinking to about $55.50 per month in 2024.

In addition, CMS noted 73% of MA enrollees will have no premium increase if they remain in the same plan. CMS is anticipating that the number of MA enrollees will increase by more than two million beneficiaries in 2024. CMS announced that 78 MA plans will participate in the Value-Based Insurance Design (VBID) Hospice Benefit model available in 19 states and U.S. territories. This model integrates hospice and palliative care into the MA plan.

Medicare beneficiaries who wish to enroll in an MA plan for CY2024 can do so during open enrollment, which runs October 15 – December 7, 2023. This is a great time for members to discuss with their clients and residents about which plans, if any, they contract with and to help educate them on their options. Members may also consider inviting their State Health Insurance Assistance Programs into their residences to make sure the older adults they serve fully understand their options for receiving Medicare services, which includes remaining in Medicare FFS and understanding if they are eligible for Low Income Subsidy assistance to pay for their Part D premiums and cost sharing.

The Medicare Payment Advisory Commission (MedPAC) met on September 7 to review a draft of a chapter on Medicare Payment Policy and to review the work they will undertake for 2023-2024. MedPAC staff identified five reports it will issue in 2024 related to Medicare Advantage (MA), including looking at plan consolidation impacts, D-SNP quality,  and standardizing MA benefits.

One report that will be of particular interest to LeadingAge members is MedPAC’s examination of access and quality in MA. Specifically, they will compare MA plan performance on ambulatory care sensitive hospitalizations, plan networks, prior authorizations, and claims denials. Several MedPAC commissioners stressed the importance of their work examining how these plans work for frail, seriously ill and nursing home beneficiaries. Other commissioners noted the need to understand the impact of plan consolidation at a more local level, include plan outcomes for the beneficiaries they serve, and provider satisfaction with MA.

New commissioner Tamara Konetzka advocated for a better understanding of how MA plans could better serve nursing home residents. MedPAC chair, Michael Chernew, did note that the goal of these reports is not to issue new recommendations in this cycle but about data collection on these issues to understand the situation.

LeadingAge will continue to monitor the Commission’s work in the coming year.

LeadingAge members are familiar with Medicare Advantage (MA) plans using third-party tools, such as NaviHealth or MyNexxus, to make generalized coverage determinations. LeadingAge has asked the Centers for Medicare & Medicaid Services (CMS) to limit use of these artificial intelligence (AI) tools, as they don’t examine the needs of the individual but instead suggest a treatment timeline based upon the typical person with the same diagnosis.

Congress has been looking at establishing some regulation around AI and on September 6, 2023, Sen. Bill Cassidy (R-LA) suggested that AI should have its own regulations in health care. He noted “a sweeping, one-size-fits-all approach for regulating AI will not work and will stifle, not foster, innovation.” The Senate is ramping up its AI work, according to Congressional Quarterly, with another Senate Commerce, Science and Transportation subcommittee hearing on AI scheduled for September 12.

The Office of Inspector General (OIG) released a July report revealing high rates of prior authorization denials in Medicaid Managed Care programs allowed to perpetuate because of limited state oversight and external medical reviews. Ranking Member of the Energy and Commerce committee, Congressman Frank Pallone (D-NJ), announced that he will be contacting each of the health insurance companies whose claims were reviewed in the OIG report. The congressman noted the responsibility of health plans to their beneficiaries and beneficiary families.

A set of new analyses released on August 9 by KFF found that Medicare Advantage (MA) plans will see a 30% increase in federal bonus payments (a program established under the Affordable Care Act that increases payments to plans based on a five-star rating system). Plans are collecting nearly $13 billion in bonus payments this year.  The papers also show clearly how most MA enrollees are paying less for coverage and gaining coverage for vision, hearing, dental, and prescription drugs.

The analyses fail to point out that coverage of post-acute care, which is far more costly than most of these other additional benefits, does not usually meet the needs of MA plan participants, even though Medicare Advantage beneficiaries are supposed to receive comparable coverage to fee for service Medicare. LeadingAge’s March 16 white paper, Fulfilling the Promise of Medicare Advantage, offers recommendations for the Department of Health and Human Services to improve the program to ensure the best care for beneficiaries, emphasizing reimbursement, contracting, and transparency.

KFF released on a new brief, How Do Dual-Eligible Individuals Get Their Medicare Coverage? Medicare and Medicaid provide health coverage to 12.5 million individuals who are enrolled in both programs, known as “dual-eligible individuals.” The brief shows that 49% of duals are enrolled in Medicare Advantage and 51% are in Traditional Medicare, and 30% of duals are in dual-specific plans (DSNPs, Medicare-Medicaid Plans, PACE, and FIDE SNPs), while 19% are in regular Medicare Advantage Plans.

AHIP, the American Hospital Association, American Medical Association and the Blue Cross Blue Shield Association sent a letter on July 27 to CMS Administrator Chiquita Brooks-LaSure, requesting that Centers for Medicare & Medicaid Services (CMS) not implement its proposal in the Advancing Interoperability and Improving Prior Authorization (AIIPA) proposed rule. The groups noted that, if implemented, these rules would conflict with electronic transaction standards proposed for health care attachments. This may be why the proposed AIIPA rule has not yet made its way to the Office of Management and Budget as a final rule.

Congress continues to apply pressure to CMS to make changes to prior authorization practices. The House Ways & Means Committee passed the Health Care Transparency Act of 2023 (HR 4822) on July 26 that includes language from last year’s bipartisan bill, Improving Seniors’ Timely Access to Care Act, which seeks to improve prior authorization processes through electronic transmissions and track plan prior authorization data.

Sen. Bernie Sanders (I-VT) also included language to improve prior authorization processes in a bipartisan HELP Committee bill entitled, Primary Care and Health Workforce Expansion Act. This proposal similarly seeks electronic prior authorizations, requires a prior authorization to cover an entire course of treatment, and for plans to track and report on certain data related to their prior authorization decisions.

LeadingAge seeks improvements in prior authorization and long-sought reductions to the administrative burden of prior authorizations remain a congressional priority. For more information, see our Fulfilling the Promise: Medicare Advantage paper, and statement to the Senate Homeland Security & Government Affairs Permanent Subcommittee on Investigations held a hearing on May 17, 2023.

Centers for Medicare & Medicaid Services (CMS) released data on skilled nursing facilities (SNF) utilization patterns for Medicare Advantage (MA) enrollees between 2016-2019 using MA encounter data. The data shows a few notable takeaways:

• A slight uptick in the percentage of MA enrollees aged 65+ utilizing SNF services between 2016-2019.
• MA enrollee admissions aged 65+ per 1,000 increased from 49.53 to 52.96 over this time period.
• The total days per admission decreased from 23.04 days to 20.40 days.

On behalf of the Better Medicare Alliance (BMA), Avalere Health issued a report updating a 2018 analysis that compares demographic and clinical characteristics of Medicare Advantage (MA) and FFS beneficiaries. The study uses 2019 claims and demographic data to reach its conclusions with a focus on  three key diagnoses—hypertension, hyperlipidemia and/or diabetes. Demographically, MA enrollees are more racially and ethnically diverse (28% in MA versus 12.5% in FFS) and have more social risk factors.

The report notes that MA enrollees had lower rates of inpatient utilization and emergency room visits and slightly higher rates of physician visits. MA enrollees who did incur an inpatient stay stayed there on average two days longer than their FFS counterparts. On this latter point, the report doesn’t address whether the long length of stay was the result of an inability of the MA plan to find a post-acute care provider to accept the individual.

Also of note, longer hospital stays don’t result in higher spending for the plan since hospitals are paid essentially a flat rate by diagnosis. The report also finds that MA enrollees with the three studied diagnoses had lower overall health care spending. In this case, we must question whether this lower aggregate spending is the result of plans paying providers less per unit of service and/or reducing the number of units of services delivered.  MA enrollee per member per month spend for MA enrollees in the subgroups ranged was roughly 70% of FFS spending. Skilled nursing facilities and home health agencies report MA plans paying them roughly 60-80% of FFS rates. Regardless of amount spent and changes in utilization patterns, the report finds that quality was similar between MA and FFS.

The current rate setting structure for Medicare Advantage (MA) plan payments results in plan overpayments of more than 20%, according to a new study from the University of Southern California Schaeffer Center. This finding is particularly galling when these same plans are often paying Skilled Nursing Facilities(SNFs) and Home Health(HH) agencies only 60-80% of what Medicare FFS pays and denying MA enrollees access to medically necessary Medicare A & B services.

Read the full LeadingAge article here.

The Centers for Medicare & Medicaid Services (CMS) looks at Medicare Advantage (MA) enrollees use of Skilled Nursing Facility (SNF), examining the data by type of entitlement and demographic characteristics, including whether they are dual eligible and area of residence.

• The data shows the percentage of MA enrollees with a SNF stay has remained fairly constant between 2016 and 2019, but the length of those stays are 11% shorter in 2019 than in 2016, with roughly 3.6 fewer days per person and almost three fewer days per admission.
• When examining demographics of the 2019 MA population, CMS notes nearly 41% of MA enrollees were dual eligible.
• While Non-Hispanic whites represent nearly 75% of all SNF admissions, they are only 67.5% of the MA population in 2019. Similarly, Black or African American MA enrollees represented 12.5% of the enrolled population but 14.5% of the SNF admissions.
• In contrast, Hispanic enrollees have disproportionately fewer SNF stays (7.7%), representing 13.7% of the enrolled population.
• It comes as no surprise that those age 85-94 have roughly 138.29 admissions per 1,000 Medicare Advantage Part A enrollees, compared to 26.96 admissions per 1000 for those age 65-74.
• Interestingly, the data shows that those under 65 years old have longer lengths of stay in SNF (average of 28.21 days per admission) than those over 65 (average of 21.19 days).
• Finally, the data shows considerable variation among states in not only their use of SNFs but also their total days per admission. Rhode Island has the highest number of SNF admissions per 1000 MA enrollees at 88.12 per 1000 but also the fewest days in SNF once admitted at 16.45 per admission.

The detailed report and spreadsheet can be found here.

In its April 2023 final CY2024 Medicare Advantage (MA) policy and technical rule, LeadingAge was pleased to see Centers for Medicare & Medicaid Services (CMS) clarified how MA plans make coverage determinations, added some guardrails on prior authorizations, and prohibited certain marketing and communication practices used by some plans and their agents. However, it remains to be seen if these new regulatory changes will truly affect change, if current enforcement and oversight is sufficient to achieve the goals of the changes, or if plans will continue to flout requirements or find new loopholes to avoid compliance.

Read the full article for detailed information on the final rule and what to expect when it is applied.

The Senate Homeland Security & Government Affairs Permanent Subcommittee on Investigations held a hearing on May 17 on the practice of Medicare Advantage (MA) plans denying care and creating access to care issues. LeadingAge submitted a statement to the subcommittee providing further evidence of the issues the subcommittee is exploring, and the difficulties LeadingAge members experience routinely.

For more details, read the full bulletin.

On April 14, Medicaid and CHIP Payment Access Commission (MACPAC) Commissioners and attendees heard a presentation from MACPAC staff on interview findings of beneficiaries and managed care organizations (MCOs). MACPAC serves as a non-partisan advisory and analytic agency to Congress and members of the president’s administration. The questions were designed to help interviewers better understand how appeals processes help beneficiaries access services and understanding of denials oversight in managed care.

MCOs asserted that many denials were issued because of inadequate documentation to determine medical necessity. Beneficiaries noted concerns with conflicts of interest in MCOs handling of appeals citing misaligned incentives.

Following the presentation from staff, spirited conversation and comments from commissioners aligned with many of LeadingAge’s concerns around prior authorization and denials as outlined in this LeadingAge article about our recently issued white paper, Fulfilling the Promise: Medicare Advantage. MACPAC is considering recommendations and LeadingAge will continue to monitor and engage on developments.

Centers for Medicare & Medicaid Services (CMS) issued its final CY2024 rate notice for Medicare Advantage (MA) plans. In addition to changes about how MA plans are paid, the notice also includes changes that reduce out-of-pocket costs for Part D enrollees.

Click here for more details on what is in the rate notice.

A possible concern about the rate notice and the CMS final rule on recouping plan overpayments, is that we might see plans more aggressively reduce provider rates in the coming year to offset any losses they experience. We are expecting the CY2024 MA policy and technical change final any day now. It contains provisions that could limit prior authorizations by the plans among other changes.

Medicare Advantage (MA) organizations benefitted from temporary enforcement discretion related to certain MA policies during the COVID Public Health Emergency (PHE). Some plans used this accommodation to make mid-year benefice enhancements to their plans. For example, some plans added an opportunity for some of their enrollees to receive in-home food delivery benefit.

Centers for Medicare & Medicaid Services notified that this enforcement discretion would end with the PHE on May 11 and this will prohibit plans from providing any expanded or additional benefits, including cost-sharing reductions if they are not already in the plans benefit package that was approved for Contract Year 2023 that started January 1, 2023.

CMS announced March 31 that Medicare Advantage (MA) plans will receive a 3.32% rate increase for CY2024, as part of CMS’s CY2024 Final Rate Announcement. This is a higher amount than the originally proposed 1.03% increase. A three-year phase in of the risk adjustment policy changes resulted in the additional rate increase.

The announcement also includes changes to Part D policies required by the passage of the Inflation Reduction Act (IRA) of 2022. Beginning in 2024, Part D plan enrollees will spend less money out of pocket for Part D, including no longer paying cost sharing in the Part D coverage gap or catastrophic phase. An expansion of the Low Income Subsidy program provides individuals with incomes between 135-150% of the Federal Poverty Level with $0 Part D premiums and low-cost, fixed copayments for covered prescription drugs. Insulin products will not be subject to the Part D deductible and plans are prohibited from charging more than $35 for a one-month supply of covered insulin products. Part D enrollees can access adult vaccines, recommended by the Advisory Committee on Immunization Practices (ACIP) at no cost and outside their Part D deductible. The final notice also caps Part D base beneficiary premiums at the lessor of 6 % or the amount that would have applied without the IRA.

The CMS Fact Sheet provides further details on the changes CMS is implementing related to risk adjustment and Part D policies.

LeadingAge expects the CY2024 MA policy and technical changes final rule to be issued later this week. The proposed rule contained key changes to MA prior authorization practices.

LeadingAge, the association of nonprofit providers of aging services, unveiled a series of solutions to the critical and growing failures of Medicare Advantage (MA) to provide equitable access to needed post-acute services. The new report, Fulfilling the Promise: Medicare Advantage, explains the issues and offers policy recommendations.

“Whether it’s delayed claims processing and opaque explanations for prior authorizations or slow care approvals, MA plan practices and policies impact the entire health care system,” said Katie Smith Sloan, president and CEO, LeadingAge. “Failure to address these and a host of other issues now will jeopardize the health and well-being of millions of older adults as the MA juggernaut expands. The time is right to take action.”

Read the full LeadingAge press release.

LeadingAge published a white paper, “Fulfilling the Promise: Medicare Advantage,” which articulates the breadth of challenges faced by Medicare Advantage (MA) enrollees when attempting to access their Medicare benefits through MA and by PAC providers in caring for these individuals. It also offers solutions to resolve these issues to support providers and ensure beneficiaries’ equitable access to needed PAC. The paper lays out the issues and corresponding solutions in the following areas:

• Making payment rates adequate and predictable
• Understanding and addressing challenges with prior authorizations.
• Bringing the vision of high-quality care closer to routine practice by making value-based arrangements workable.
• Giving beneficiaries a true choice of high-quality providers by addressing network adequacy.
• Addressing transparency concerns by improving data collection and sharing.
• Actively supporting beneficiary needs and rights.

LeadingAge sent a letter to CMS Adminstrator Chiquita Brooks-LaSure on March 13 to offer support for the “Advancing Interoperability and Improving Prior Authorization Processes” proposed rule and its goals to make prior authorizations and data sharing more efficient. The letter expresses particular support for extending payer provisions to include Medicare Advantage plans. Read the full comments.

LeadingAge submitted comments Feb. 13 on CMS’s proposed rule governing how Medicare Advantage, Special Needs Plans, Part D and PACE programs will operate in CY2024 offering support for many of CMS’s proposed rules and suggestions for further refinement. While the comments cover a wide swath of topics, as did the proposed rule, the majority of the LeadingAge comments honed in on members’ pain points – how MA plans make coverage determinations for traditional Medicare Part A & B services and prior authorizations.

Read the full LeadingAge article.

A group of US Senators who sit on the Senate Finance Committee issued a Request for Information in Dec. 2022 seeking input on how to reform health care to achieve integrated care for dual eligibles. LeadingAge submitted comments on January 13 sharing its vision of integrated care from its 2017 white paper including highlighting member integration models  with better outcomes for senators to consider.

LeadingAge met with Senate staff recently to discuss these ideas further and learn how we can assist the Senate in their efforts to improve care for the dual eligible population.  This group of senators – Sens. Bill Cassidy, M.D., Thomas Carper, Tim Scott, Mark Warner, John Cornyn and Robert Menendez – continue to meet weekly on this topic and synthesize the responses they received from the RFI.  They’re working toward identifying some concrete solutions for discussion in the coming months.

Centers for Medicare & Medicaid Services (CMS) issued its annual proposed rule (CMS-4201-P) on December 7 to update the Medicare Advantage (MA) policies and technical changes that will apply to MA, Special Needs Plans (SNPs), Part D plans, and PACE programs and benefits beginning with Calendar Year 2024. The 957-page proposed rule also seeks to address: placing additional limits on permissible marketing to beneficiaries, revising the MA and SNP Star Rating System including a health equity index reward, improving access to behavioral health; affordability, and access in the Part D drug program, and expanding Part D low-income subsidies and timely access to more beneficiaries.

Read the LeadingAge article for detailed analysis.

LeadingAge took the opportunity to comment on Centers for Medicare & Medicaid Services (CMS) request for information on various aspects of Medicare Advantage (MA) Program and submitted comments to CMS Administrator Chiquita Brooks-LaSure on August 31. The comments reflect the perspective of providers of post-acute care, long-term services and supports, and home and community-based services who contract with Medicare Advantage and Special Needs Plans to provide services.

LeadingAge President and CEO, Katie Smith Sloan, sent a letter to CMS Administrator Chiquita Brooks-LaSure and CMS Director of Medicare Meena Seshamani on Monday, July 18 outlining concerns we have related to the future of Medicare and Medicare Advantage and asking to meet. The goal of the meeting would be to discuss the challenges providers face in delivering Medicare benefits in both programs and how we might work with CMS to ensure beneficiary access to services through the two programs as well as financial sustainability for providers. Dr. Seshamani quickly responded to the request and a meeting is being scheduled.

A new report from the Office of Inspector General (OIG) reviews the appeals and grievance systems for Medicaid managed care programs. With more than 70% of Medicaid enrollees receiving services through managed care, the Centers for Medicare and Medicaid Services (CMS) started requiring states monitor appeals and grievances data for plan performance. The report found wide variation in appeal and grievance rates across and within states.

OIG found significant gaps in the data collection which, if unaddressed, could limit CMS’ use for oversight moving forward. OIG made the following two recommendations to CMS: First, the Administrator of CMS should require states to report on the outcomes of Medicaid managed care appeals (e.g., the extent to which they were decided in favor of enrollees) and number of denials. Second, the Administrator of CMS should implement its planned actions for analyzing the Medicaid managed care appeals and grievances data, using it for oversight, and making it publicly available.

LeadingAge will be participating in a May 1 roundtable conducted by the Urban Institute to explore issues and improvements to the Medicare systems for filing complaints, with a particular focus on Medicare Advantage (MA) plans. We are seeking member input by April 30 to inform our comments at the roundtable

Our position to date has been that there should be a dedicated provider complaint line for MA where issues can be identified, tracked for trends and resolved promptly related to plan non-compliance. Here are some questions to prompt members’ thinking on this topic but other thoughts are welcome:

• What are the top three MA issues or complaints you wish you had somewhere you could report them and obtain resolution?
• How quickly do these issues require resolution?
  • Within 24 hours
  • Within a few days
  • Within a week
• What is the reason they can’t get resolved currently?
• What happens if they remain unresolved (e.g., beneficiaries lose services, provider not paid, etc.)?

Ideas or examples can be sent directly to Nicole Fallon, preferably no later than April 30.