When traditional Medicare has “fully established” coverage criteria, Medicare Advantage (MA) plans won’t be able to use their own internal version to deny claims starting Jan. 1. That’s one of the provisions in CMS’s 2024 rule on policy and technical changes to MA that health care organizations hope will result in what they consider a fair shake in medical reviews.^[1]

Although CMS has always required MA plans to provide at least the same coverage as traditional Medicare, it clarified they can’t deny benefits based on coverage criteria that doesn’t meet the updated language in the rule, said Richelle Marting, an attorney and certified coder in Olathe, Kansas. For example, MA plans aren’t allowed to use internal coverage criteria to change the two-midnight rule or the requirement for a three-day qualifying stay before a skilled nursing facility admission. MA plans may be more generous (e.g., eliminating the qualifying stay) but not more restrictive (e.g., adding two days to it), she said.

As the rule explains, “when an MA organization is making a coverage determination on a Medicare covered item or service with fully established coverage criteria, the MA organization cannot deny coverage of the item or service on the basis of internal, proprietary, or external clinical criteria that are not found in Traditional Medicare coverage policies.”