CMS Releases Proposed MA Rule Aimed at Improving Beneficiary Access to Care
The Centers for Medicare and Medicaid Services (CMS) today released the Contract Year (CY) 2026 Medicare Advantage (MA) and Part D proposed rule, which aims to hold MA plans more accountable. The release of this rule comes during the Lame Duck period, and it is unclear whether or how the incoming Trump Administration will proceed with these proposed policies.
Specifically of interest to long term and post-acute care providers, the proposed rule focuses on:
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Strengthening Oversight on Prior Authorization and Utilization Management –The rule proposes stricter policies on how MA plans handle prior authorizations using internal coverage criteria, emphasizing patient safety and requiring clearer, more transparent internal coverage criteria to reduce denials. It also aims to increase guardrails on the use of artificial intelligence and prevent automatic denials of basic benefits without individual assessments.
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Enhancing Transparency and Access to Information – The proposed rule requires MA plans to provide accurate provider directory information to CMS to post on the Medicare Plan Finder. It also mandates clearer communication from agents and brokers about assistance programs and the implications of switching from MA to Traditional Medicare.
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Protecting Beneficiaries from Misleading Practices – The proposed rule introduces measures to stop misleading advertising, particularly regarding supplemental benefits, and aims to improve protections against deceptive marketing by broadening CMS oversight of MA and Part D communications.
AHCA has advocated for additional beneficiary protections, encouraging CMS to continue its oversight of prior authorizations and utilization management to ensure these practices are adhered to and plans are held accountable. Recent research shows that denials for post-acute care increased between 2019 and 2022, and that seniors are leaving MA plans for traditional Medicare. Additionally, CMS has determined that on average, MA plans overturn 80 percent of their decisions to deny claims, but less than 4 percent of denied claims are even appealed.
AHCA will continue to review the proposed rule, which will be published on the Federal Register on December 9, and provide a detailed summary soon. AHCA will also submit comments to CMS by the January 27, 2025, deadline.
Please reach out to Nisha Hammel at AHCA with questions.
Reported on by:
Skilled Nursing News
McKnight's LTC News
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