CMS Final Rule 2024: Updates and Implications for Payers – Part 2

As Medicare Advantage (MA) open enrollment is currently in full swing, it’s the ideal time to circle back and delve deeper into the substantial changes outlined in the 2024 Medicare Advantage and Part D Final Rule (CMS-4201-F).¹ These changes, rooted in a resolute commitment to equity and enhanced healthcare access, are designed to safeguard beneficiaries, bolster quality measures, and promote health equity among all Medicare recipients.

In part one of this two-part blog, we examined the key changes to utilization management, marketing requirements, the Star Rating Program, and CMS’s efforts to advance health equity. In this second part, we’ll continue to explore the key provisions of the final rule and the impact on payers.

Behavioral Health Accessibility: Enhancing Support

The CMS final rule includes several changes to ensure that enrollees have timely access to the behavioral health care they need, including:

• Expanding network standards and telehealth credit eligibility to clinical psychologists and licensed clinical social workers
• Adding behavioral health services to general access to services standards
• Codifying standards for appointment wait times for primary care and behavioral health services
• Clarifying that emergency behavioral health services must not be subject to prior authorization
• Requiring MA health plans to notify enrollees when their behavioral health or primary care providers are dropped midyear from networks
• Requiring MA organizations to establish care coordination programs that include behavioral health services

These new requirements could be challenging for payers to implement, particularly smaller payers with limited resources. Payers may need to invest in new systems, such as network management, prior authorization, and care coordination systems, to comply with the new requirements. Additionally, they may have to expand their networks to include more behavioral health providers to enhance enrollees’ access to behavioral healthcare.

Implementation of Certain Provisions of the Consolidated Appropriations Act, 2021 and the Inflation Reduction Act of 2022

The Consolidated Appropriations Act (CAA) of 2021 (Division B, Section 118) makes the Limited Income Newly Eligible Transition (LI NET) Program permanent. The LI NET Program provides immediate and retroactive Part D coverage for eligible low-income beneficiaries who do not yet have prescription drug coverage. This change will ensure that low-income individuals can access affordable prescription drug coverage as soon as they become eligible for Medicare Part D.

Beginning January 1, 2024, the Inflation Reduction Act of 2022 (IRA) [Section 13531(a)(1)(A)] expands eligibility for the full low-income subsidy (LIS) benefit (also known as “Extra Help”) to individuals with incomes up to 150% of the federal poverty level. This change will provide the full low-income subsidy to those who currently qualify for the partial subsidy, improving access to affordable prescription drug coverage for approximately 300,000 low-income individuals with Medicare.

These changes will impact payers in several ways. First, the permanent extension of the LI NET Program and the expansion of eligibility for the full LIS benefit will increase enrollees receiving subsidies for their prescription drug coverage. This could lead to increased costs for payers.

• However, payers can mitigate these costs by taking several steps, including:
• Investing in utilization management tools and services ensures enrollees receive the most appropriate and cost-effective care.
• Leveraging data analytics to identify and address trends in their claims data that could lead to increased costs.
• Implementing performance improvement initiatives to improve the quality and efficiency of their operations.
• Developing and implementing strategies to attract and retain low-income enrollees.

Implementation of Certain Provisions of the Bipartisan Budget Act of 2018 and the CAA of 2021

The final rule finalizes several changes to the Medicare Part C and D programs stemming from the Bipartisan Budget Act (BBA) of 2018 (Public Law 115-391), the CAA of 2021, and the Inflation Reduction Act (IRA) of 2022 (Section 13531).

Key changes include:

• Expanded access to supplemental benefits: MA plans can now offer a wider range of supplemental benefits, such as transportation and meals.
• Promoted value-based care: MA plans are encouraged to adopt payment models that reward providers for delivering high-quality care at a lower cost.
• Protected beneficiaries from high out-of-pocket costs: MA enrollees have capped out-of-pocket costs in Part C and Part D.
• Capped the annual increase in the base beneficiary premium for Medicare Part D at 6%.
• Provided a $3,200 annual out-of-pocket cap for insulin.

The changes will significantly impact payers, requiring them to adapt their business models and partner with providers to improve the quality and efficiency of care delivery. However, the changes also offer opportunities for payers to serve more enrollees and expand their offerings.

Navigating the CMS Final Rule Changes

The CMS final rule updates for 2024 will significantly impact payers, but they also present an opportunity to transform healthcare delivery. At HealthAxis, we are committed to helping payers navigate these changes and emerge stronger than ever.

Schedule a discovery call today to learn how HealthAxis can help you transform your health plan operations with our cutting-edge CAPS technology, modern BPaaS/BPO capabilities, and industry expertise.

Source:
1. Fact sheet 2024 Medicare Advantage and Part D Final Rule (CMS-4201-F), CMS