Some Medicare Advantage plans are not planning to comply with new CMS guidance requiring plans to follow traditional Medicare's standards for coverage decisions, the American Hospital Association alleges.
In a letter to CMS published Nov. 20, the AHA said it has received reports from some of its members that "certain [Medicare Advantage organizations] have indicated they do not intend to make changes to their utilization management programs in response to the new rule."
In April, CMS issued its final rule for Medicare Advantage plans for contract year 2024. The rule established that MA plans cannot apply coverage standards that differ from traditional Medicare, except in cases where Medicare's coverage criteria is not fully established.
In its letter, the AHA alleged that UnitedHealthcare's 2024 inpatient coverage guidance indicates the plan intends to use internal coverage criteria beyond traditional Medicare's standards.
"We are deeply concerned that these practices will result in the maintenance of the status quo where MAOs apply their own coverage criteria that is more restrictive than Traditional Medicare proliferating the very behavior that CMS sought to address in the final rule, resulting in inappropriate denials of medically necessary care and disparities in coverage between beneficiaries in MA and those in the Traditional Medicare program," Ashley Thomspon, senior vice president of public policy analysis and development for the AHA, wrote.
The AHA also alleged Aetna's 2024 "two midnight rule" guidance applies stricter standards than those used in traditional Medicare.
Under the two midnight rule, inpatient admissions are covered for traditional Medicare beneficiaries who require more than a one-day stay in a hospital or who need treatment specified as inpatient only. Stays lasting less than two midnights must be treated and billed as outpatient. CMS' final 2024 rule for Medicare Advantage established MA plans must also follow this determination, with some case-by-case exceptions.
In a message to providers cited by the AHA, Aetna said it will follow the two midnight benchmark in 2024. It will review if inpatient admissions were appropriate based on "what the physician reasonably should have known or should have expected at the time of admission."
The AHA alleged this standard is more stringent than CMS' guidance for determining medical necessity of inpatient admissions based on "what the physician knew or expected at the time of admission."
"This is an example of an MA plan changing CMS rules and applying more restrictive standards in a way that could be used to justify denials of inpatient care that would have been covered under traditional Medicare," the AHA wrote in its letter.
The association asked CMS to clarify its 2024 rule and to take "swift action," including sanctions when appropriate, against plans violating its rules.
Becker's has reached out to Aetna and UnitedHealthcare for comment and will update this article if more information becomes available.