On February 6, 2024, CMS released an FAQ memo clarifying how a new Medicare rule (Final Rule) and the Affordable Care Act impact the use of AI and algorithms by MA organizations in making Medicare Advantage coverage determinations. The final rule (CMS Final Rule, CMS-4201-F) became applicable to coverage beginning January 1, 2024.
The 2024 Medicare Advantage and Part D Final Rule (CMS-4201-F), issued by the Centers for Medicare & Medicaid Services (CMS), introduces significant changes to enhance the Medicare Advantage (MA) and Medicare Part D programs. Let’s delve into the key provisions:
- Timely Access to Care: Utilization Management Requirements:
- CMS has addressed concerns related to prior authorization by MA plans, ensuring timely access to medically necessary care for enrollees.
- The final rule clarifies that MA plans must comply with national coverage determinations (NCD), local coverage determinations (LCD), and general coverage and benefit conditions from Traditional Medicare regulations.
- When coverage criteria are not fully established, MA organizations may create internal coverage criteria based on widely used treatment guidelines or publicly available clinical literature.
- This promotes transparent, evidence-based clinical decisions consistent with Traditional Medicare1.
- AI and Algorithms in Medicare Advantage Coverage Determinations:
- Payment Increase for Medicare Advantage Plans:
- Health Equity Index Reward:
For more details, you can refer to the official CMS fact sheet. The changes aim to improve healthcare delivery and ensure better outcomes for Medicare beneficiaries.
LEARN MORE – FAQ MEMO
Posted In: Resource Information
