Medical person places hand on patient in gesture of reassurance

Two proposed rules should help patients improve their Medicare Advantage plan selections while standardizing expectations for skilled nursing and other healthcare providers, federal officials reiterated Tuesday.

And in other highly anticipated actions, the Centers for Medicare & Medicaid Services has completed a study of minimum staffing standards for nursing homes and is considering its policy options.

Both pieces of news came during a wide-ranging CMS stakeholders call, which largely recapped much of the agency’s 2022 policy-setting and enforcement work.

On the MA front, Mary Green, MD, director of the Office of Burden Reduction & Health Informatics, said requests for information and two rules proposed in December would address challenges patients face when trying to access care, as well providers’ obstacles in delivering that care.

MA prior authorizations and denials with little recourse have caused major operational and financial concerns for skilled nursing providers over the last few years.

“Prior authorization is an important utilization management tool, but when it’s onerous to get through the process, that’s a problem for everybody involved,” Green acknowledged. “Patients may unnecessarily pay out of pocket or abandon treatment altogether when prior authorization delays care. Prior authorization also is a leading cause of burnout among clinicians.”

Those concerns are expected to grow as the number of Medicare beneficiaries opting for MA plans over the traditional fee-for-service plan grows. MA enrollment recently surpassed 30 million for the first time, and criticism by elected officials and national media has mounted as seniors often find themselves unable to obtain care when they need it most, particularly near the end of life.

Green said the latest MA proposed rules are intended to make care more “efficient, transparent and standardized” and make quick access to care more routine.

“It proposes timeframes around how quickly some payers would need to respond to prior authorization requests and require payers to publish certain metrics around the rates of approval and appeals,” she added. “It gives patients more visibility into how plans handle prior authorizations, and that information might be helpful to patients when they’re selecting the health plan they want to join.” 

Payers also would have to improve the electronic exchange of health data to support prior authorization and develop a way to securely share attachments, such as patient charts or lab results, to speed the process.

Those changes were inspired by more than 4,000 comments providers and patients submitted after CMS last summer issued a request for information on MA experiences. The respondents included hundreds of skilled nursing providers and the aging services group LeadingAge, which said pricing and denial tactics by some plans were sending providers into a “death spiral.”

CMS Director of Medicare Meena Seshamani said Tuesday that those comments helped shape proposed regulations for 2024.

“The proposed rule takes important steps to protect beneficiaries and enhance Part D 

Benefits,” she said.” And it provides additional guidance to help CMS effectively collaborate 

with health plans and others to best meet the needs of people enrolled in MA.”

In other news from Tuesday’s call:

  • Jean Moody-Williams, deputy director of the Center for Clinical Standards and Quality, reported the CMS study to assess minimum staffing requirements — including a literature review, nursing home site visits and cost analysis — had been concluded. 

“The report includes recommendations of potential barriers to and unintended consequences of implementing the recommendations and cost implications,” Moody-Williams said. “We are currently reviewing it to determine our policy direction.”

A minimum staffing proposal, first broached by the White House last February, is widely expected to be proposed some time this spring. Just this week, senators from several states asked CMS to resist a “one-size-fits-all” approach, given labor issues that are worse in some areas of the country.

  • CMS Principal Deputy Administrator and Chief Operating Officer Jon Blum noted that the agency had hired for about 500 positions in late 2022, but that it still has about 700 open jobs, or about 10% of the agency’s workforce.