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CMS Final Rule regarding Medicare Advantage Plans

June 6, 2023

By: Andrea Greenblatt

, its case-by-case exception, the inpatient-only (“IPO”) list, as well as traditional Medicare coverage criteria.[1]

CMS explicitly stated that the 2-midnight rule under traditional Medicare is applicable to MA Plans. However, CMS draws a line with respect to the 2-midnight “presumption” arguing that MA Plans may continue to use prior authorization or concurrent case management review of inpatient admissions under either the 2-midnight rule or its case-by-case exception.

Further, CMS confirms that “MA Plans may not use InterQual or MCG criteria, or similar products, to change coverage or payment criteria already established under traditional Medicare laws.” Thus, MA Plans must follow coverage criteria set forth in applicable Medicare statutes, regulations, National Coverage Determinations (“NCDs”) and/or Local Coverage Determinations (“LCDs”), unless they are not fully established, or additional, unspecified criteria are needed to interpret or supplement general provisions in order to determine medical necessity consistently. In such case, MA plans may create internal coverage criteria that are based on current evidence in widely used treatment guidelines or clinical literature that is made publicly available.  The clinical literature acceptable for use to justify the MA Plan internal coverage criteria includes “large, randomized controlled trials or prospective cohort studies with clear results, published in a peer-reviewed journal, and specifically designed to answer the relevant clinical question, or large systematic reviews or meta-analyses summarizing the literature of the specific clinical question.”

Overall, the rule represents a significant step forward in strengthening the MA program and improving the quality of care for patients. Wolfe Pincavage’s team is well-versed in navigating the Medicare Advantage rules and regulations, and guides providers, hospital systems, and physicians’ groups through every aspect of it.

[1] Centers for Medicare & Medicaid Services, “Medicare Program; Contract Year 2024 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicare Cost Plan Program, and Programs of All-Inclusive Care for the Elderly.”