CMS released the Medicare Program; Contract Year 2024 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicare Cost Plan Program, Medicare Parts A, B, C, and D Overpayment Provisions of the Affordable Care Act and Programs of All-Inclusive Care for the Elderly; Health Information Technology Standards and Implementation Specifications. See proposed rule changes here. 

The experts at ATTAC have reviewed the proposed rule changes, and here’s our summary of what may impact your plan the most:

ACA HHS Risk Adjustment Data Validation

Proposed HHS RADV changes:  

  • Beginning with 2022 benefit year, change the materiality threshold established under § 153.630(g)(2) for random and targeted sampling from $15 million in total annual premiums statewide, to 30,000 total billable member months statewide, calculated by combining an issuer’s enrollment in a state’s individual non-catastrophic, catastrophic, small group, and merged markets, as applicable, in the benefit year being audited. 
  • Shorten window to confirm findings of the second validation audit (SVA) if applicable, or file a discrepancy report to dispute SVA findings, to within 15 calendar days of notification by HHS, beginning with 2022 benefit year. 
  • Solicit comments on discontinuing use of the lifelong permanent condition list and the use of Non-EDGE Claims in HHS RADV 

Here’s what you should consider now: 

  • How will the move from $15M in annual premiums to 30,000 billable member months affect your organization? What about the potential for smaller HIOS IDs to be randomly selected for HHS RADV audit?  
  • Are you prepared to complete discrepancy reviews and report disputes to CMS within 15 days?  What resources will you need to comply with a 15-day review window?  
  • How will discontinuation of the Life Long Permanent Condition (LLPC) list and/or the use of Non-EDGE Claims (NEC) affect your overall validation rate? Have you done the analytics, reviewed EDGE submission challenges/errors, reviewed prior use NECs and/or necessary medical record documentation reviews for your LLPCs to figure out how these change may impact your audit results?  

Medicare Advantage Agent/Broker Compliance Oversight

Medicare Advantage marketing practices remain the subject of heightened scrutiny by CMS. The proposed rule changes will require plans to have an active agent and broker monitoring and oversight plan that monitors and reports noncompliance.

We expect that CMS will make few, if any, changes to the proposed compliance monitoring and oversight for plan year 2024. Medicare Advantage organizations and Part D sponsors should begin creating a robust program for the 2024 annual enrollment period (AEP) that incorporates the following:

·         Review of internal grievances

·         1-800- MEDICARE complaints

·         Random sampling audits of real-time and past audio sales, marketing and enrollment calls

·         Secret shopping in-person education and sales events

·         Secret shopping web-based education and sales events

·         Targeted and tailored training and retraining programs

·         Disciplinary standards and actions

·         Internal and external reporting policies and procedures

Once the 2024 changes are final, plans will need to implement an oversight plan that monitors independent, captive or employed agents or brokers in Q4 2023 for AEP 2024. 

Medicare Advantage and ACA Provider Directories & Contracting

Health Equity

In the proposed rule, CMS wants to ensure Medicare Advantage provider directories reflect providers’ cultural and linguistic capabilities, and notate Medication for Opioid Use Disorder (MOUD) -waivered providers. The directory changes would mirror Medicaid requirements and:

  • Include non-English languages spoken by each provider
  • Include provider/location accessibility for people with physical disabilities
  • Include indicator for MOUD-waivered providers

CMS intends to monitor compliance with new directory requirements. Website directories must be searchable by indicators.

Are you prepared to capture this information and publish it in your directory for AEP?

Behavioral Health

CMS has proposed adding three new provider types, subject to time and distance network adequacy reviews:

  • Clinical psychology
  • Clinical social worker
  • Prescribers of medication for opioid-use disorder (MOUD)
  • Time, distance and ratios
  • 10% credit for telehealth providers for behavioral health

These new minimum appointment wait-time standards would be added to the existing requirement that Medicare Advantage organizations establish written policies for the timeliness of access to care and member services. Organizations must have appointment wait times that meet or exceed the standards proposed.

Are you prepared to include these provider types in your network and achieve network adequacy?

Proposed ACA Changes

  • Expansion of Essential Community Provider (ECP) requirement to add two additional stand-alone ECP categories: Mental health facilities and substance-use disorder treatment centers.
  • Adding rural emergency hospitals as a provider type in the other ECP providers’ category.
  • Requiring QHPs to contract with at least 35% of available FQHCs and at least 35% of available family planning providers that qualify as an ECP in the plan’s service area. This is in addition to meeting the current overall 35% ECP threshold requirement in the plan’s service area.
  • Revising network adequacy and ECP standards to require all individual market QHPs and SADPs and all Small Business Health Options Program (SHOP) QHPs across all exchanges to use a network of providers that complies with the network adequacy and ECP standards, and to remove the exception that these requirements do not apply to plans that do not use a provider network.

Contact ATTAC Consulting Group to learn how we can help your plan prepare for the proposed changes.