FAQs Elaborate on MA Rule; CMS Audits Will Cover 88% of Enrollees

In new FAQs, CMS clarified the ties that bind Medicare Advantage (MA) plans in terms of coverage and payment denials courtesy of a 2024 rule—and said that enforcement of the rule is getting under way.[1] Already complaints about MA plan noncompliance may be shaking things up.

“When we submit examples of MA plan noncompliance with longstanding policy or clarifications made in the 2024 final rule, I am not asking for CMS to help get claims paid,” said Richelle Marting, director of managed care at North Kansas City Hospital in Kansas City, Missouri. “I am reporting examples of MA plan noncompliance by using claims as examples to illustrate the noncompliant activities.” Already, the FAQs have been helpful in reinforcing her perception that some MA plans are not complying with aspects of the MA rule.

The 2024 rule on policy and technical changes to Medicare Advantage codifies that MA plans must live by the same coverage and payment criteria as traditional Medicare, such as the two-midnight rule, and may only use internal coverage criteria in medical necessity determinations when Medicare coverage criteria isn’t “fully established.”[2] CMS has made it abundantly clear that MA plan coverage is not allowed to be more restrictive than traditional Medicare policies found in national coverage determinations (NCDs), local coverage determinations and Medicare laws.

The Feb. 6 FAQs are seen as a way to get MA plans to accept the inevitable, said Ronald Hirsch, M.D., vice president of R1 RCM. “From what we have been hearing, several of the MA plans had not quite gotten the message that this [rule] applies to them,” he said. “CMS is facing a lot of pressure from the American Hospital Association and everybody else to make sure MA plans are following the rules.”

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