Recently, the Centers for Medicare and Medicaid Services (CMS) finalized regulations that establishes operating requirements for Medicare Advantage (MA) plans operating in 2024 . This is an annual process and AOPA provided comments last year as the rule was being drafted, but the 2024 final rule will require MA plans to operate much more similarly to the traditional, fee for service-based Medicare program. The final regulations represent the most sweeping changes to the operating requirements MA plans must abide by and, in general, will create greater transparency and accountability to Medicare beneficiaries. Highlights of the final regulations include the following:
- Require MA plans to abide by fee-for-service Medicare coverage rules
- Limit the use of internal MA or proprietary coverage guidelines
- Establish guardrails around the use of prior authorization (PA)
- Strengthen medical necessity determinations
- Create new standards for MA reviewers who deny claim
The O&P Alliance has prepared a detailed analysis of the final regulations including the potential impact on the O&P profession. The analysis may be accessed here. The final regulation itself may be accessed here.
AOPA will develop member resources that will help you further understand the impact of the regulations and communicate with your Medicare Advantage contract partners.