January 1st kicked off a new year; and for skilled nursing facilities and Medicare Advantage beneficiaries, this new year offers big opportunities to get the access to care needed. Powerful changes included in the Medicare Advantage (MA) Contract Year (CY) 2024 Final Rule went into effect on 1/1/2024.

Biggest Changes Beginning 1/1/24

The most significant changes drastically impact prior authorization use and medical necessity determination.

The MA Final Rule states that prior authorization will only be used to confirm a diagnosis or other medical conditions; a beneficiary with a confirmed diagnosis will no longer need prior authorization from their MA insurer. For example, a beneficiary being admitted from the hospital would already have a confirmed diagnosis and therefore, would not need prior authorization. Taking this a step further, once prior authorization is granted, it will remain valid as long as medically necessary.

With changes implemented by the MA Final Rule, medical necessity will now be determined by a beneficiary’s prior medical history and recommendation of the treating physician. This is a massive change to improve beneficiaries’ access to a full episode of care. Previously, the medical director of the MA insurer determined medical necessity; with this change, the physician who is actually treating the patient will make that decision.

Providers and beneficiaries can also expect that MA plans will now align coverage more closely to traditional Medicare and follow traditional Medicare benefit guidelines, LCDs, and NCDs. When coverage criteria is not defined by the Medicare Benefit Policy Manual, LCDs, or NCDs, then MA insurers may use internal coverage guidelines. It will be important to push MA insurers on use of internal guidelines; the MA Final Rule states internal guidelines must be publicly available and provide a public summary of evidence considered during the development of internal coverage criteria.

So, Now What?

This is the most progress made in decades to take control back from MA insurers! However, we’ve already encountered some insurers playing games. As expected, many MA organizations (MAOs) will not happily comply with new requirements that hurt their bottom line. In many cases, information is simply not being communicated; MAO leaders are not passing along information or changing policies to accommodate new requirements. Meaning, MA case managers working with SNFs may not even be aware of the MA Final Rule’s existence, may not be properly educated on its requirements, or may purposefully misinterpret changes. After all, remember how MA insurers have conducted business for over a decade.

Medicare Advantage isn’t going anywhere, and MAOs know it. In 2023, more than 50% of all Medicare eligible beneficiaries were enrolled in an MA plan. In many regions of the US, that percentage is even higher, and providers are faced with the hard truth that they must accept MA plans in order to maintain a census.

So, it’s time to think about how you’re going to manage MA insurers.

First, read the MA Final rule and be prepared to use that language with insurers, to specifically cite new requirements. Make sure your Case Manager and Admissions Director also have a copy of the Final Rule.

Then, SNFs should initiate the conversation with their MA case managers. Explain that you are familiar with the new Final Rule requirements, you know they have to make changes in their practices and clarify your expectations. Now is the time to tell MA insurers and case managers what you want.

If you receive pushback, feel empowered to call your CMS regional office to let them know you have a MA provider who is not following the Final Rule and not providing beneficiaries with access to care. Inform your MA case manager that you will be calling your CMS regional office.

When preparing for your conversation with CMS, it is important to remember that CMS’s top priority is the beneficiary and their care. It is essential that you connect how the MA insurer’s actions are preventing or limiting the beneficiary’s access to care. As appropriate, key phrases to consider are:

• “The MAO is limiting beneficiary’s access to care.”
• “The MAO is not providing the same coverage as traditional Medicare.”
• “The MAO is not following the CY 2024 MA Final Rule guidelines.”

SNFs, this is a call-to-action! Let’s take the progress made in the MA Final Rule and band together, CMS will listen when SNFs NATIONWIDE prove that MA insurers are not following the guidelines CMS detailed in the new regulations.

The Future Looks Bright

CMS released the CY 2025 MA Proposed Rule on 11/15/2023. This included another massive change for MAO practices, proposing the appeal process for MA denials move to a traditional five-level appeal process, as used in traditional Medicare appeals.

Currently, the MA plan appeal process consists of three levels. Levels ne and two are reviews by the denying insurer, and level three is a peer review by the insurer’s physician, educated on the insurer’s rules.

CMS’ proposal would allow providers and beneficiaries to work with an independent reviewer. Staff from the nation’s 53 CMS affiliated Quality Improvement Organizations (QIO) would review untimely, fast-track appeals of any MA plan’s decision to terminate services.

Further, the proposed rule eliminates the requirement for beneficiaries to forfeit their right to appeal a termination of services decision when they leave the facility.

How Can We Help?

Celtic Consulting, a post-acute advisory firm, provides operational, clinical, and financial support to health care providers. Celtic has partnered with SNFs for over twenty years; guiding facility teams through many changes impacting reimbursement, regulatory compliance, operations, and accuracy.

Our team of subject matter experts provide appeals and denials management assistance to clients nationwide. Further, Celtic Consulting specializes in managed care accounts receivable and revenue collections and has helped clients collect millions of dollars of outstanding revenue.

Contact Celtic today, let’s discuss how we can assist your organization.