What: In the latest Biden administration effort to rein in Medicare Advantage, CMS issued a final rule prohibiting “misleading” Medicare Advantage advertisements plus other abuses.
Why: Last year, the Senate Finance Committee released a report highlighting an increase in deceptive Medicare Advantage plans’ marketing practices targeting seniors and recommended that CMS take action to reduce the prevalence of such marketing tactics.
Why It Matters: Seniors and people with disabilities are complaining about misleading and confusing Medicare Advantage and Part D plans ads. The final rule includes changes to protect people those types of misleading marketing practices. Below is a summary of some rules:
A Few Details:
Prohibits advertisements that do not mention a specific plan name, misrepresents what a plan offers, and uses Medicare logos or language in a way that could mislead and confuse enrollees into believing that the advertisement is for traditional Medicare.
Clarifies criteria guidelines to help ensure that people with Medicare Advantage receive access to the same “medically necessary” care they would receive with traditional Medicare.
Expands the list of populations to which Medicare Advantage companies must provide “culturally competent” services, such as people with limited English proficiency or those in the LGBTQ community.
Requires that a prior authorization approval for care remain valid for as long as “medically necessary” to avoid disruptions in care for beneficiaries.
Minimum wait time standards for behavioral health and requiring that most types of Medicare Advantage plans include behavioral health services.
Support: The American Hospital Association applauds the action because Medicare Advantage beneficiaries are routinely experiencing inappropriate delays and denials for coverage of medically necessary care. It noted that this rule will protect patients, ensure timely access to care, and reduce administrative burdens on an already strained health care workforce.
Other Action: On Friday, CMS issued controversial final payment policies for 2024 seeking to limit over billing by Medicare Advantage plans, e.g., updating the risk adjustment model to better ensure that payments are in line with patients’ medical conditions and prohibit insurers from adding diagnoses to inflate their billing.
Yes But: Insurers protested the proposed rule vehemently, leading CMS to phase in the changes over three years, instead.