The Centers for Medicare and Medicaid (CMS) released the 2024 Medicare Advantage Proposed Rule on December 14, 2022 and the 957 page document is scheduled to enter the federal register on December 27th, 2022. This sprawling proposal for the Medicare Advantage program includes updates and policy changes to the Star program, clarifies prior authorization adjustments, enhances member access to behavioral health services and new health equity focused requirements.
3 Key CMS Star Program Takeaways
CMS is using all the tools at its disposal to advance Health Equity initiatives including the Star program. This comes as no surprise as the federal government made their commitment to reduce disparities in care a top priority and adopted Health Equity as a pillar in the 2022 CMS Strategic Plan. CMS has previewed their intent to introduce a Health Equity index reward aimed at incentivizing innovation and improved care outcomes for socially disadvantaged and underserved populations in previous memos and notices. To be successful at achieving this reward, plans will need a platform to both identify their at-risk cohorts based on SDOH data and manage outreach to members with care gaps.
-Also included in the proposal is a reduction to member experience measures in the Star rating calculations. CMS is keeping plans on their toes as they move from quadruple weighted member experience measures to just double weighted. Plans will need to continue to consider how workflows, access to care and other interactions impact member perception across the care continuum but these measures will become slightly less significant to the overall rating.
Removal of the hold harmless provisions for 4- and 4.5-star plans is sure to hit many rising plans hard in ratings. This provision historically excluded improvement measures from the calculation for 4 star and higher plans if its inclusion could negatively impact the overall rating. This change, to only apply the provision to 5-star plans, could result in an overall rating drop for 4.5 and lower plans.
Prior Authorization Clarifications
CMS has been busy streamlining prior authorization policies with the help of interoperability standards. Earlier this month the “CMS Advancing Interoperability and Improving Prior Authorization Processes” proposed rule was published which focused on enhancing member’s timely access to care. The new proposed rule clarifies and further enhances these goals.
The new proposed rule provides further clarity on services which do not fall into existing statutes or regulated coverage determination criteria. CMS is proposing that plans will be required to supply evidence-based criteria for clinical determinations and that a health care professional with expertise in the field of service be involved before any denial is issued.
Behavioral Health Insights
In the proposed rule, CMS emphasizes the importance and growing need for mental health services. As the industry and regulatory bodies spotlights health equity, we’re also taking note of the important role behavioral health (BH) plays in improving health outcomes. Many clinicians, especially those serving disadvantaged populations, know all too well how lack of timely BH care significantly impairs their ability to avoid health crises for their population. Often BH networks are overloaded and inadequate to meet the demand resulting in long waitlists.
CMS proposes adding social workers and other BH providers to the evaluated specialists for network adequacy requirements. They also propose new rules for BH wait times as well as notifications to members when their BH provider leaves the network.
As whole-person care models grow in adoption and becomes required for managed care organizations, CMS is also proposing that plans include BH in their programs, services, and care plans.
2 Key Health Equity Takeaways
As we look to addressing health disparities, CMS wants to ensure that plans provide culturally competent communications and services to their members. CMS’ proposal to expand the group of cultural competencies mentions inclusion for language and reading deficiencies, gender identity, sexual orientation, disabilities, and socio-economic status. To ensure that all groups have access to equitable care, plans will need to embrace community-based partnerships and seek representation across their staff.
A key tool in reaching underserved communities is telehealth services which allow members with mobility, transportation, and other restrictive struggles to access care virtually. Telehealth has risen in popularity since CMS expanded policies during the COVID-19 pandemic. CMS is proposing a new requirement that plans provide digital health literacy education to members with the goal of promoting access to care through use of telehealth services.
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As Director of Population Health Informatics for ZeOmega, Cindy Henry is responsible for product innovation and market expertise in population health management and value-based care.
Cindy is a member of the Product Planning team contributing subject-matter expertise to shape the product roadmap and provide thought leadership. She collaborates with other experts, clinicians and development teams to survey regulations, monitor policy changes, and research market trends to ensure ZeOmega’s products continue to meet the evolving and emerging needs of our clients.
Cindy began her career in population health in 2015 as a Business Intelligence Project Manager at North Texas Specialty Physicians (NTSP), an independent physician association and parent company of Care N’ Care, a Medicare Advantage plan in Texas. While at NTSP, she held several titles including business analyst, project manager, and interim manager for the Business Intelligence and Application Development teams. Before coming to ZeOmega, Cindy was the Medicare Advantage Product Manager for a PHM startup company.