Despite early fears, long-term care leaders have some reason to be optimistic that changes to Medicare Advantage rules for 2024 will be enforced.
“Key decision makers” at the Centers for Medicare & Medicaid Services assured a coalition of industry leaders that “they intend to use their full array of tools” to ensure the MA plans stick to rule changes, according to Nicole Fallon, vice president of integrated services and managed care at LeadingAge.
CMS intended the rule changes, which went into effect Jan. 1, to broaden protections under MA — including clarifying coverage rules, limiting plan denials and restricting when technology could be used to make decisions about ending coverage. But associations and consumer advocates saw worrying signs that MA plans were unlikely to significantly change their policies in reaction to the rules.
‘Enhanced’ enforcement
CMS outlined their plans to enforce the changes in a Jan. 3 call with a coalition of long-term care leaders and advocates — such as the American Health Care Association and the Center for Medicare Advocacy. While much remains to be seen, CMS showed a willingness to work with the sector on its concerns, Fallon told stakeholders at a LeadingAge policy call Wednesday.
“The big news is about how they are approaching the audit process. They called it an ‘enhanced audit process,’” Fallon explained. “Plans will have a focused audit that will look at compliance with the coverage and utilization management policies and all of the rules related to access to care and services…. In addition, they said [CMS leaders] intend to use their ‘full array of tools’ in making sure folks comply.”
That toolbelt will include fines, publicly reporting on noncompliant plans and requiring such plans to make corrective action roadmaps followed by an independent audit to confirm the corrections were actually implemented.
For systemic or unusually egregious violations, CMS could also step in with serious sanctions.
“Sanctions prohibit the plans from enrolling any new beneficiaries,” Fallon explained. “That’s hitting them in the gut because if they can’t get their enrollees they’re not getting new dollars.”
A receptive CMS
Additional guidance and educational materials are still in the works at CMS, but the federal agency’s enhanced regulatory tactics signaled an intent to ensure MA plans comply with rule changes, and do so quickly.
CMS often gives plans some leeway to adjust before fully enforcing MA rule changes, but they expect plans to be in compliance with the newest rules within the current year, according to Fallon.
Overall, sector leaders and CMS representatives seemed committed to the same results around the new MA rules.
“Our concerns are valid and they wanted to hear from us,” Fallon said. “We intend to be partners in this work.”
