Charles Baker, VP, Compliance Solutions | Victoria Nadzam, MSN, RN
CMS has announced significant revisions to Medicare Advantage Part C and Prescription Drug plans. These changes, related to enrollee grievances, organization/coverage determinations, and appeals guidance, will take effect on January 1, 2025 and will affect plans nationwide. The updates aim to enhance clarity, streamline processes, and expand enrollee rights.
Key Changes at a Glance
- Extended Appeal Timeframes
- Previous Regulation: Enrollees had 60 calendar days from the date of the notice to file an appeal.
- Updated Regulation: The appeal period has been extended to 65 calendar days.
- Revamped Standardized Notices
- Previous Regulation: Standardized notices including the Notice of Denial of Medical Coverage (CMS-10003) and the Notice of Denial of Medicare Part D Drug Coverage (CMS-10146) featured technical language that was often challenging for enrollees to understand.
- Updated Regulation: CMS updated these notices to use plain language and improved formatting, making them easier for enrollees to read and understand.
- Expanded Fast-Track Appeal Rights in The Notice of Medicare Non-Coverage (NOMNC)
- Previous Regulation: The NOMNC offered limited guidance on appeal rights for enrollees who missed the deadline or ended services before the planned termination date.
- Updated Regulation: Enrollees may request a review by a Beneficiary and Family Centered Care Quality Improvement Organization, even if they missed the initial appeal deadline or ended services early.
- Enhanced Detailed Explanation of Non-Coverage (DENC)
- Previous Regulation: The DENC lacked specific instructions for handling repeat appeals within the same episode of care.
- Updated Regulation: Plans must now specify changes in the enrollee’s condition since the prior appeal when deciding to terminate services within same episode of care.
- Uniform Implementation Deadline
- Previous Regulation: Varied implementation timelines led to inconsistencies in compliance across different plans.
- Updated Regulation: Medicare Advantage organizations and Part D plan sponsors must implement updates by January 1, 2025.
Implications for Medicare Advantage and Part D Plans
With the rapidly approaching implementation date, plan sponsors should take proactive steps to align with new requirements:
- Update and test the notices in your clinical management system, claims system, and any letter system that generates these notices.
- Share notice changes with your delegated vendors and first-tier entities to ensure they update systems to meet the deadlines.
- Share notices with contracted skilled-nursing facility provider and ensure that they understand the changes in the discharge appeal processes.
Policies and Procedures Updates
Update any related policies and procedures to incorporate the regulatory changes:
- Staff Training: Educate team members on revised appeal timeframes and updated notice formats to ensure accurate and timely communication with enrollees. Educate staff regarding revised discharge appeal process for skilled nursing facility providers and any policy/procedure changes.
- Process Audits: Review and adjust current procedures to comply with extended appeal periods and enhanced notice requirements.
- Beneficiary Communication: Use updated, plain-language notices to improve enrollee understanding and satisfaction.
By embracing these changes, plans can enhance compliance, reduce the risk of audit findings, and provide a more transparent and supportive experience for enrollees.
Don’t let the changing tides in Medicare Advantage Part C and Part D compliance jeopardize your plan’s financial health and market position. Talk with an ATTAC compliance expert about how we can help your plan craft its strategy for success.
About ATTAC Consulting Group
ATTAC Consulting Group is nationally recognized as an expert in regulatory interpretation, design, and operation of effective compliance programs for Medicare, Medicaid and commercial health plans, PDPs, ACA plans, ACOs, IPAs, medical groups, dental and vision plans.
