The Centers for Medicare and Medicaid Services (CMS) recently updated its complaint submission form and process to receive complaints regarding Medicare Advantage (MA) plans regarding noncompliance with the 2024 Medicare Advantage rule. The rule, which went into effect January 1, 2024, generally limits MA plans to the utilization review and prior authorization requirements under original Medicare and places conditions on use of internal coverage criteria. It also required MA plans to follow the two-midnight rule regarding determination of inpatient versus observation services.
A CMS FAQ document regarding what is required of MA plans under the rule is here. The FAQs detail when and how insurers are permitted to use internal coverage criteria instead of federal standards, as well as requirements for public disclosure of those criteria. (Andrew Busz, andrewb@wsha.org)
