What’s happening: The Centers for Medicare & Medicaid Services (CMS) proposes policy changes for Medicare Advantage (MA) plans in contract year (CY) 2025.
What else to know: Comments on the proposed rule, which addresses MA policies such as prior authorization, outpatient behavioral health and supplemental benefits, are due Jan. 5.
- Outpatient Behavioral Health: CMS proposes adding a range of behavioral health providers under one category called “outpatient behavioral health” as a facility-specialty for network adequacy standards. Specialists under this category include marriage and family therapists, mental health counselors, opioid treatment program providers, community mental health centers, addiction medicine physicians, and other providers who currently furnish addiction medicine and behavioral health counseling or therapy services in Medicare.
- Quality Improvement Organization (QIO) Review of Non-Hospital Services Coverage Termination Decisions: CMS proposes requiring a QIO to review untimely fast-track appeals of an MA plan’s decision to terminate services in a skilled-nursing facility, comprehensive outpatient rehabilitation facility, or by a home health agency.
- Increase Percentage of Duals Receiving Integrated Care: The proposed rule increases the percentage of dually eligible MA enrollees who are in Medicaid plans by offering more opportunities for enrollment in integrated plans and more opportunities to switch to traditional Medicare.
- Health Equity Analysis of Utilization Management (UM) Policies: If finalized, the rule would require MA plans to ensure a member of its UM committee have expertise in health equity and the committee conduct an annual equity analysis of prior authorization policies.
- Increase Awareness of Supplemental Benefits: CMS proposes a “Mid-Year Enrollee Notification of Unused Supplemental Benefits” be issued annually to each enrollee who lists any supplemental benefits not used during the first six months of the year.
- Part D Biosimilar Substitution Flexibility: CMS proposes to provide more flexibility to substitute biosimilar biological products other than interchangeable biological products for their reference products. The proposal would permit Part D plans to treat such substitutions as maintenance changes so that the substitutions apply to all enrollees, not only those who begin the therapy after the effective date of the change, following a 30-day notice.
CHA is currently reviewing the rule and will make a detailed summary available to members soon.
