Kristen Bond Dobson Details CMS Amendments to Medicare Advantage Regulations

In April 2023, the Centers for Medicare & Medicaid Services (CMS) released a final rule amending Medicare Advantage (MA) regulations, focusing on coverage criteria and prior authorization processes. The rule was a response to concerns from healthcare providers and other stakeholders about inappropriate delays in securing coverage decisions as well as denials by Medicare Advantage Organizations (MAOs). The rule took effect on June 5, 2023, and applies to coverage starting January 1, 2024. On February 6, 2024, CMS issued FAQs to clarify these new regulations.

Healthcare Associate Kristen Bond Dobson summarizes the new CMS regulations and FAQs, which are part of a broader effort to ensure MAOs provide coverage consistent with traditional Medicare laws and to address concerns about prior authorization practices. Notably, the FAQs clarify that MAOs are not to use artificial intelligence tools alone in making coverage determinations. Instead, such determinations must be based on the circumstances of the specific individual.

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