Medicare Advantage (MA) plans are going to want to take note of two recent HPMS memos from the Centers for Medicare and Medicaid Services (CMS). Each touches on major areas of controversy for the program.
Supplemental Benefits User Group
CMS will host a user group to provide an overview of supplemental benefits data submission for encounter data records on September 26, 2024, 2:00 p.m. – 3:00 p.m. ET. You need to register in advance. See the flyer distributed with the September 10 HPMS memo on the topic.
The issue of supplemental benefits is an explosive one right now. Opponents of MA say that MA plans are submitting bids that misrepresent supplemental benefit utilization and thereby inflating their margins. CMS has little to go by because encounter data for supplemental benefits is rarely submitted.
CMS did two things to attack the controversial issue. First, it issued a memo requiring plans to submit supplemental benefits encounter records. It has been programming its system and giving guidance to plans on how to submit. Second, it has mandated that plans perform education on supplemental benefits and issue a mid-year, member-specific supplemental benefits utilization review. See my previous blog on this topic here: https://www.healthcarelabyrinth.com/medicare-advantage-plans-need-to-get-their-focus-on-supplemental-benefits-quickly/
In the blog, I admonished MA plans to get their acts together on supplemental benefits for fear of further harsh actions from CMS. MA plans must master submission, as hard as that will be. The user group is a great opportunity to submit questions and offer suggestions. There is no doubt the process will be fraught with errors and take time. After all, most supplemental benefits are not routine health services and CMS is looking for reporting for each usage of any benefit (with some limited exceptions.)
A series of policy memos, technical memos, and software update memos have been issued via HPMS beginning in February of this year on the subject. CMS will take questions in advance regarding the February 21, 2024 memo, “Submission of Supplemental Benefits Data on Medicare Advantage Encounter Data Records,” and other supplemental benefits related topics. MA plans can send questions to RiskAdjustmentOperations@cms.hhs.gov. Questions should be submitted by September 20, 2024. Specify “9/26/24 Supplemental Benefits User Group” in the email subject line.
Medicare Part C Utilization Management Annual Data Submission and Audit Protocol Data Request
CMS also recently issued a new data submission requirement relating to a 2024 rule involving utilization management (UM) and prior authorization (PA). The draft document is: “Medicare Part C Utilization Management Annual Data Submission and Audit Protocol Data Request” (CMS-10913; OBM control number: 0938–New). There is a comment period for MA plans.
In April 2023, CMS issued the 2024 rule that made major changes to UM and PA for MA plans. It finalized updates to the MA utilization management program requirements in §§ 422.101 and 422.137 that clarified coverage criteria for basic benefits and the review of utilization management tools. I have been very critical of requirements that MA plans follow traditional fee-for-service (FFS) protocols when deciding to approve or deny a coverage request. I think that CMS is trying to take the managed care out of Medicare Advantage.
CMS is now using its authority under Section 1857(d) of the Social Security Act to oversee MA plans’ compliance with these new program requirements through the collection of data. CMS is proposing an annual collection of organizations’ internal coverage criteria and the utilization management audit protocol data request. This will be used to assess overall compliance and to choose plans for annual audits on the UM and PA changes. This past year, CMS performed ad hoc audits independently and during program audits. CMS will make these permanent submissions and audits similar to timeliness monitoring.
Here is my take on this development. The ad hoc audits on the UM and PA changes were pretty light in 2024 because they were brand new. Both CMS and plans were getting their footing. CMS largely looked at documentation and lightly reviewed cases related to the change. I think this data request will begin the process of much greater scrutiny of MA plans and their compliance with FFS rules. Pay particular attention in the future to how CMS reviews and holds MA plans to account on the two-midnight inpatient and post-acute care provisions embedded in FFS protocols. How aggressive CMS is on these will dictate the magnitude of increased costs to MA.
There is a 60-day public comment period on the proposed collection, which started September 10, 2024. The proposed collection can be viewed here: https://www.federalregister.gov/documents/2024/09/10/2024-20400/agency-information-collectionactivities-proposed-collection-comment-request . Comments must be received by November 12, 2024. CMS especially wants comments on the Supporting Statement A Background section.
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— Marc S. Ryan
