NADP Highlights MA Technical Changes in CMS CY 2025 Proposed Rule

November 29, 2023

In service to our members, NADP summarized key provisions of the recent Centers for Medicare & Medicaid Services (CMS) Contract Year 2025 Policy and Technical Changes to the Medicare Advantage Plan Program. The Rule revises requirements of Medicare Advantage plans on the federal exchanges for the plan year 2025. There have been several changes to supplemental benefit utilization in this proposed rule. Many proposed changes derive from policies outlined in President Biden’s Competition Council and Executive Order signed in July 2021.

NADP published the following summary in the Advocacy Open Forum of Dental Interact.

Annual Health Equity Analysis of Utilization Management Policies and Procedures

The proposed rule states that Medicare Advantage plans must analyze their utilization management (UM) policies and procedures from a health equity perspective. CMS is proposing updates to the Utilization Management (UM) committee to require:

• A member of the UM committee to have expertise in health equity.
• The UM committee conducts an annual health equity analysis of prior authorization policies and procedures used by the Medicare Advantage plan organization.
• Medicare Advantage plan organizations will make the analysis results publicly available on their website.

Mid-Year Enrollee Notification of Available Supplemental Benefits

CMS is proposing plans to make consumers aware of their supplemental plan benefits by:

• Engaging in minimum outreach efforts, making enrollees aware of the available supplemental benefits.
• Annually, issue a “Mid-Year Enrollee Notification of Unused Supplemental Benefits” personalized to each enrollee, including a list of any supplemental benefits not accessed during the year’s first six months.
  • Include the scope of the benefit, cost-sharing, instructions on how to access the benefit, any network application information for each available benefit, and a customer service number to call if additional help is needed.

New Standards for Supplemental Benefits for the Chronically Ill

CMS proposes that Medicare Advantage plans must:

• Demonstrate, by the time they submit bids, that SSBCI items and services meet the legal threshold of having a reasonable expectation of improving chronically ill enrollees’ health or overall function and are supported by research.
• Establish and maintain bibliographies of relevant research studies or other data to demonstrate that an SSBCI meets these requirements.
• Update SSBCI marketing requirements to prevent misleading marketing related to these benefits, making it appear that the benefits are available to everyone.

Standardize the Medicare Advantage Plan Risk Adjustment Data Validation (RADV) Appeals Process

CMS proposes changes that will address operational constraints. MA organizations can:

• Request only a medical record review determination appeal or payment error calculation appeal for purposes of reconsideration, and not both simultaneously.
• Request a medical record review determination appeal may only request a payment error calculation appeal after the completion of the medical record review determination administrative RADV appeal process.

NADP will continue to provide updates as our advocacy develops. Contact Government Affairs Analyst Bernice Ogbondah for additional information.