Medicare Advantage enrollment continues to grow. More than half of all eligible people with Medicare are in a Medicare Advantage plan. 

But that doesn’t mean it’s been smooth sailing for Medicare Advantage leaders. CMS continues to issue updated policies and brand-new regulations for MA plans to follow, with the overarching goal of improving transparency, easing access to care, and empowering consumer choice.

Leaders must keep their eyes on the radar to stay informed on updated policies and determine where they’re heading. That way, they can continue to grow membership and thrive against the competition. 

Prior Authorization

While an important tool for health plans to control costs and prevent fraud, waste, and abuse, the prior authorization process is burdensome for providers, health plans, and patients. 

CMS took action recently to address common pain points for all parties. For instance, a Medicare Advantage-specific prior authorization rule, finalized in April 2023, requires:

  • A 90-day transition period for an enrollee who switches to a new MA plan
  • The establishment of a Utilization Management Committee to review prior authorization policies annually
  • The approval of a request to be valid for as long as medically necessary for a course of treatment

Furthermore, CMS finalized an additional prior authorization rule in January 2024. In 2026, payers will need to send prior authorization decisions within 72 hours for urgent requests and seven business days for standard requests. 

These changes are designed to make care easier to access for enrollees. Investing in the technology, staff, and other capabilities needed to meet these requirements is imperative for the future success of any Medicare Advantage plan.

Network Adequacy

Among Medicare Advantage enrollees, 28% live with a mental illness, according to the Commonwealth Fund. The COVID-19 pandemic brought with it an increase in the use of alcohol and other addictive substances.

CMS addressed both of these in 2023, proposing policies to improve access to behavioral health services (mental health and substance abuse treatment programs) for Medicare beneficiaries.

The federal agency finalized payment for new behavioral health categories: intensive outpatient programs (IOPs), performed by hospital outpatient departments, and intensive outpatient services provided by opioid treatment programs (OTPs). Payment for crisis services outside of clinical settings, timed behavioral health services, and substance use disorder treatment also increased.

Specifically for Medicare Advantage plans, CMS proposed updating network adequacy standards for contract year 2025. The rule would add behavioral health providers into a category called Outpatient Behavioral Health and add that category as a facility specialty with network adequacy standards. 

Easing access to needed care, like behavioral health care, will no doubt continue to be a trend in years to come.

Price and Data Transparency

CMS finalized the Transparency in Coverage Rule in 2020 as a way to empower healthcare consumers to make informed decisions about their health.

The rule had a phased implementation approach. In July 2022, plans had to publicly post machine-readable files on their website detailing various pricing data, including covered items and services from in-network providers and allowed amounts for out-of-network providers.

By January 2023, payers needed to have an online price comparison tool that members could use to estimate what they would pay for 500 shoppable services.

And now, as of Jan. 1, 2024, the capabilities of that tool needed to expand to include all items and services.

This rule brought unprecedented transparency to the health insurance industry — and the Biden administration has signaled it wants to take transparency in Medicare Advantage even further in coming years to even further empower enrollees. “The lack of transparency in Medicare Advantage managed care plans deprives patients of important information that helps them make informed decisions,” HHS Secretary Xavier Becerra said in a January 2024 statement.

Medicare Star Ratings

The Medicare Star Ratings program gives Medicare beneficiaries a way to evaluate the quality of available plans at a glance, and it is also the basis for quality bonuses from CMS. A higher rating makes plans more marketable to enrollees. In fact, 74% of people enrolled in an MA plan with Part D coverage are in a contract that has a 4-star or higher rating. 

CMS issued an update to the methodology for the 2024 star ratings, which included retiring some quality measures (such as kidney disease monitoring as part of diabetes care) and adding others (such as transitions of care and follow-up after an emergency department visit for people with multiple high-risk chronic conditions). Read specifics of those changes here

Chart the path forward

Any health plan leader is used to riding the waves of change as the government updates and adds policy regulations. But savvy leaders will take heed of the current direction — toward more transparency, more empowered consumers, and easier access to care — and see it as an opportunity for innovation and positive change.