Members Encouraged to Monitor and Report Medicare Advantage Plan Compliance
As OHA continues to support the American Hospital Association’s efforts to seek more rigorous enforcement and oversight of Medicare Advantage plans, it is imperative that hospitals and health systems report examples of non-compliance, especially when patient care and access are being inappropriately denied or impeded, to federal regulators.
CMS in April 2023 issued its CY 2024 Medicare Advantage and Part D Final Rule (CMS-4201-F) which increases oversight of Medicare Advantage plans and seeks to better align MA coverage with Traditional Medicare. Key provisions of the final rule which went into effect on Jan. 1, 2024, include:
- Direct MA plans to adhere to the two-midnight rule for coverage of inpatient admissions
- Require MA plans to comply with national coverage determinations, local coverage determinations, and general coverage and benefit conditions included in Traditional Medicare laws
- Clarify that the CMS inpatient-only list applies to MA plans
- Prohibit MA plans from denying payment for a service based on medical necessity if the service was prior authorized
OHA encourages members to monitor MA plan behavior and compliance by collecting metrics such as average length of stay for observation cases and number of observation stays exceeding two midnights by MA plan and Traditional Medicare. Members should consider comparing pre- and post- Jan. 1, 2024 metrics to monitor the effects of the CY 2024 MA Final Rule.
Examples of non-compliance and supporting metrics should be submitted to Ohio’s CMS Regional Office, Region 5 – Chicago, at ROCHIORA@cms.hhs.gov. CMS requests that providers include specific information on individual cases such as:
- MA plan name
- Provider facility/hospital name
- Dates of request
- MA plan reference/case number for specific cases (this to minimize PHI transmitted via email or send PHI encrypted)
- Was the request to the MA plan expedited or standard,
- The amount of time after the response was late
- MA plan staff/delegated vendor name
- MA plan responses
- Any other relevant provider-plan communications for specific cases
As OHA meets with our CMS Regional Office monthly, we intend to inform the Regional Office of MA plan compliance with this rule. To help OHA inform the agency of MA plan compliance and behavior and to encourage swifter action by the agency to implement more oversight and enforcement mechanisms, please contact Quyen Weaver to share your experiences with any MA plan and their adherence to the CY 2024 MA Final Rule.