Medicare Advantage in 2024—New rules, new loopholes

8 minute read

In the utilization management world, the adoption of CMS-4201-F—the new rule regulating many Medicare Advantage (MA) plan activities—was a game changer.[1] Like many new rules, the adoption of the rule by the Centers for Medicare & Medicaid Services (CMS), brought with it confusion over when the provisions became applicable. The final rule was published on April 8, 2023, and had an effective date of June 5, 2023, but it also specified that for most provisions, the applicability date was January 1, 2024. Under these new regulations, the MA plans have had to abide by several requirements that they previously stated did not apply to them.

These new requirements include recognizing the many nuances of the two-midnight rule, including the two midnight expectation, the Medicare Inpatient Only list, the exception for unplanned mechanical ventilation, the case-by-case exception, and the one-day inpatient admissions due to death, transfer against medical advice, hospice, and unexpected rapid recovery. In addition, in CMS-4201-F, CMS reiterated that the MA plans must honor Medicare criteria for access to inpatient rehabilitation admissions, skilled nursing facility care, and home health care.

But for 2024, there remain many ways that MA differs from traditional Medicare, and understanding these is crucial. While these differences are based on regulation, it is essential to note that individual plans may choose to follow these guidelines.

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