Earlier this month, the Centers for Medicare & Medicaid Services (CMS) released their long-awaited 2024 Medicare Advantage (MA) final rule - full text and fact sheet. The final rule comes at a pivotal time for Medicare Advantage plan regulations, care access, health equity, social determinants of health (SDoH), and more in the space, and now sets the stage for 2024 and beyond for 30+ million Americans.

These are the most important updates brought about by the 2024 CMS final rule.

Stars Ratings Tackle Health Equity

MA plan Stars ratings have been on a continual evolutionary process for the past few years, and the path ahead looks no different as CMS continues to optimize the Stars rating system for greater quality outcomes and health equity.

In the final ruling, CMS announced the addition of a health equity index (HEI) reward for the 2027 Stars ratings. The HEI helps to encourage MA plans to “improve care for enrolled with certain social risk factors.” The CMS has the advancement of health equity as the first pillar of its 2022 strategic plan, and they are acting on this pillar by incentivizing health plans to tackle certain social risk factors (SRFs) that relate to health outcomes that are evident before provided care, not consequences to the care quality, and not easily modified by care providers. This makes transportation access and issues a key SRF for the HEI award.

Additionally, in the final ruling, the CMS reverses its course on member experience from previous years by reducing the weight of patient experience/complaints and access measures as to better align with other CMS programs around quality. They acknowledge that they had received feedback concerned that the patient experience/complaints were weighted higher than the clinical outcomes measure. This shift will start with the 2026 Stars ratings and will allow MA plans to equally focus on driving member-centric experience while improving their clinical outcomes.

Cultural Competency + Health Equity = Better Member Experience

The CMS’ approach to addressing health equity isn’t just reflected in the Stars rating updates, it’s also evident through the push for improving cultural competency towards underserved populations within MA plans. In the final ruling, CMS has doubled down on providing support to a broader range of vulnerable groups who have faced persistent inequality in healthcare by expanding the list of example populations that MA plans must provide services in a culturally competent manner. These groups include:

1. Racial or ethnic minority groups
2. LGBTQI+ community
3. Limited English proficiency
4. Disabilities
5. Rural populations
6. Below or near the poverty level

While the CMS understands none of these may be the sole determinant of an individual’s health, they are a significant contributing factor. These groups have long faced barriers and gaps in accessing care.

One of the largest barriers has been a lack of cultural competency from plans, plan partners, and care providers– and defining this list of groups helps demonstrate how each stakeholder will need to adapt. When plans are culturally competent, they provide their beneficiaries a line of communication with individuals they can relate to whether by language, location (rural or urban), sexual orientation, etc. These efforts around cultural competency can make all the difference in helping members have a better experience, be more engaged with their plan, and stay on their plan longer – driving member experience, engagement, and retention.

Cultural competency is a significant opportunity for all stakeholders across the healthcare continuum. For instance, if plans and plan vendors are building out a call center staff, a recommendation would be to hire members who speak a range of dialects so that when a Spanish speaking member from Colombia calls, they can relate to a fellow Colombian Spanish speaker and not a Nicaraguan Spanish dialect. Big or small, these considerations and decisions can make a big difference for members.

Prior Authorization

To date, prior authorization has been a shortcoming for most–if not all–types of health plans. Whether when a member is in need of timely treatment or in need of a treatment that bridges while transitioning from one health plan to another, not having prior authorization to kick off care can have a significant impact on the health outcome of a patient. CMS has noted these challenges and takes a significant stance on prior authorizations in four ways through this final rule.

1. Prior authorization policies for coordinated care plans 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 based on the standards specified in this rule.
2. Prior authorization processes must be valid for as long as medically necessary to avoid disruptions in care in accordance with applicable coverage criteria, the patient’s medical history, and the treating provider’s recommendation.
3. Plans must provide a minimum 90-day transition period to members who are currently undergoing an active course of treatment when they are switching to a new MA plan.
4. MA plans must comply with national coverage determinations (NCD), local coverage determinations (LCD), and general coverage and benefit conditions included in Traditional Medicare laws. This includes criteria for determining whether an item or service is a benefit available under Traditional Medicare.

These changes are crucial to ensuring coverage and continuity in the care that MA beneficiaries receive. In addition, this significantly levels the playing field between MA and traditional Medicare to keep the medically-necessary level of care consistent. These all clearly align with the consistent trend seen of placing a greater emphasis on member-centric experience across healthcare.

Other Key Changes

Marketing Crackdown

Digital literacy is a known challenge for MA plans and for this vulnerable population. The final rule shows that CMS is stepping up to protect beneficiaries from parties looking to take advantage of their lack of digital literacy. Now, all ads must mention a specific plan by name and can not use words, images, or logos that may confuse beneficiaries. The final rule also empowers MA plans to monitor their agents and brokers’ activities. This is a great step to provide greater transparency and reduce the saturation of marketing to a vulnerable elderly population.

Behavioral Health Accessibility

The CMS is prioritizing behavioral health with key changes in the final ruling including:

1. Ensure clinical psychologists and licensed clinical social workers are attributed as specialty types for network standards, making these services eligible for the 10-percentage point telehealth credit.
2. Amend general access to services standards to explicitly include behavioral health services.
3. Codify standards for appointment wait times for primary care and behavioral health.
4. Not allow emergency behavioral health services to be subject to prior authorization.
5. Require MA plans to notify when a behavioral health or primary care provider drops midyear from their network.
6. Require MA plans to establish care coordination programs across community, social, and behavioral health services for improved whole-person care.

Prescription Drug Coverage

The final rule updates the Inflation Reduction Act to allow for greater access to affordable prescription drugs. Eligibility is expanding for the full low-income subsidy benefit to allow for individuals with up to 150% of the federal poverty level. Prescription drugs play a vital role in maintaining care adherence and better health outcomes for individuals across the care continuum.

Looking Ahead

The final rule is a timely update that helps narrow the expansive health equity gap that exists for far too many Americans who deserve high-quality, life-sustaining care. SafeRide Health tracks all of these trends to help our Medicare Advantage plan partners stay ahead of the curve. To achieve the goals set forth by the CMS, Medicare Advantage plans will continue to prioritize investments in addressing members’ social needs first, and diverse, forward-thinking partners like SafeRide empower them to do so while delivering optimal levels of care, member experience, and ultimately, health outcomes.