CMS finalizes rule addressing Medicare Advantage marketing, prior authorization

CMS issued a final rule April 5 that, among other things, aims to streamline Medicare Advantage and Part D prior authorizations and clamp down on misleading marketing practices. 

The rule requires that coordinated care plan prior authorization policies may only be used to confirm the presence of diagnoses or other medical criteria and/or ensure that an item or service is medically necessary, according to a CMS fact sheet. 

It also requires coordinated care plans to provide a minimum 90-day transition period when a beneficiary undergoing treatment switches to a new MA plan, according to the fact sheet. During this period, the new plan cannot require prior authorization for the active course of treatment. 

To ensure prior authorization is used appropriately, CMS is requiring all MA plans to establish utilization management committees to review policies annually and ensure consistency with traditional Medicare national and local coverage decisions and guidelines, according to the fact sheet.

The final rule also requires that approval of a prior authorization request for a course of treatment must be valid as long as medically reasonable and necessary "to avoid disruptions in care in accordance with applicable coverage criteria, the patient’s medical history and the treating provider’s recommendation." 

To address misleading marketing practices, CMS is prohibiting ads that do not mention a specific plan name as well as ads that use words and imagery that may confuse beneficiaries. It also prohibits ads from using language or Medicare logos in ways that are misleading, confusing, or misrepresents the plan.

The rule finalized a health equity index required for Star Ratings, beginning in 2027. It also expands requirements for MA plans to provide culturally and linguistically appropriate services and implements Inflation Reduction Act provisions to make prescription drugs more affordable for eligible low-income beneficiaries.  

Read the full fact sheet here

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