2023 Principle Changes to Medicare Compliance Regulations.

The principal provisions of the final rule are discussed in this fact sheet.

The final rule is available for download at https://www.federalregister.gov/public-inspection/current.

The final Centers for Medicare and Medicaid Services rule defines clinical criterion requirements to guarantee that people with Medicare Advantage (MA) receive the same medically essential care that people with Original Medicare Parts A and B beneficiaries receive. This is consistent with recent recommendations from the Office of Inspector General (OIG). CMS clarifies rules governing acceptable coverage criteria for basic benefits, requiring MA plans to comply with national coverage determinations (NCD), local coverage determinations (LCD), and general coverage and benefit conditions included in traditional Medicare regulations.

When coverage criteria are not fully established, Medicare Advantage organizations may design internal coverage criteria based on current evidence in widely accepted treatment recommendations or clinical literature that is made publicly available to CMS, enrollees, and providers. CMS clarifies when appropriate Medicare coverage criteria are not completely stated in the final rule by expressly outlining the scenarios under which MA plans may use internal coverage criteria for making medical necessity decisions. CMS believes that, in limited cases, allowing the use of publicly accessible internal coverage criteria is necessary to encourage transparent, evidence-based clinical choices by MA plans that are consistent with traditional Medicare.

The final rule also streamlines prior authorization procedures, including the addition of continuity of care criteria and the reduction of beneficiary disruptions. CMS' final rule states that prior authorization policies for coordinated care plans may only be used to confirm the presence of diagnoses or other medical criteria and/or to guarantee that an item or service is medically essential. Second, when an enrollee presently undergoing treatment transitions to a new MA plan, the new MA plan must provide a minimum 90-day transition period during which the active course of treatment may not require prior permission. Third, in order to guarantee that prior authorization is utilized effectively, CMS is requiring that all MA plans form a Utilization Management Committee to review policy and assure consistency on an annual basis.