This is the season for reporting proposed and final payment rules for FY 2024.
After a brief pause during the winter months, the Centers for Medicare & Medicaid Services (CMS) is once again issuing a number of proposed and final regulations for payments in Fiscal Year 2024. Both the Fee for Service (FFS) Medicare and Medicare Advantage changes are being proposed.
The Centers for Medicare & Medicaid Services (CMS) published the 2024 Medicare Advantage (Part C) Rate Announcement on March 31. The key item for our listeners is the revised Medicare Advantage (MA) Risk Adjustment Model. The rule includes important technical updates, including restructured hierarchal condition categories (HCCs) using the International Classification of Diseases (ICD)-10 classification system (instead of the ICD-9 classification system) and updated underlying FFS data years (from 2014 diagnoses and 2015 expenditures to 2018 diagnoses and 2019 expenditures), as well as revisions focused on conditions that are subject to more coding variation. This new model will be phased in over three years. Details of these revisions are included in the Rate Announcement.
In the 2024 Medicare Advantage and Part D Final Rule, CMS clarifies clinical criteria guidelines to ensure people with MA receive access to the same medically necessary care they would receive in traditional Medicare, by requiring that MA plans must comply with national coverage determinations (NCD), local coverage determinations (LCD), and general coverage and benefit conditions included in traditional Medicare regulations. CMS is also finalizing that when coverage criteria are not fully established, MA organizations may create internal coverage criteria based on current evidence in widely used treatment guidelines or clinical literature made publicly available to CMS, enrollees, and providers.
The final rule also streamlines prior authorization requirements. It requires that coordinated care plan prior authorization policies may only be used to confirm the presence of diagnoses or other medical criteria and/or ensure that an item or service is medically necessary; and that plans provide a minimum 90-day transition period when an enrollee currently undergoing treatment switches to a new MA plan, during which the new MA plan may not require prior authorization for the active course of treatment.
We are now in the season for proposed FY2024 Medicare Fee for Service payment and policy rules for institutional provider types. So far, CMS has published the following:
Yet to come is the 2024 Inpatient Hospital PPS and LTC Hospital PPS Rule. It should be published shortly.
Programming note: Listen to Stanley Nachimson’s live RegWatch report today on Talk Ten Tuesdays, 10 Eastern with Dr. Erica Remer and Chuck Buck.
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