Final Medicare Advantage Rule Places Greater Oversight and Restrictions on MA Plans

April 20, 2023

The Centers for Medicare & Medicaid Services (CMS) April 5 finalized its Policy and Technical Changes to the Medicare Advantage and Medicare Prescription Drug Benefit Program for Contract Year (CY) 2024. The final rule increases oversight of Medicare Advantage (MA) plans and better aligns MA coverage and utilization management requirements with those of traditional Medicare. WSHA is pleased with the requirements of the final rule as it reflects WSHA’s comments.

The final rule:

  • Prohibits MA plans from limiting or denying coverage for a Medicare-covered service based on their own internal or proprietary criteria if such restrictions don’t exist in traditional Medicare;
  • Directs MA plans to adhere to the “Two-Midnight-Rule” for coverage of inpatient admissions. Under the rule an observation stay that spans two midnights will generally be considered an inpatient stay for payment purposes, same as traditional Medicare;
  • Limits the ability of MA plans to apply site of service restrictions not found in traditional Medicare;
  • Requires MA health plan clinicians reviewing prior authorization requests to have expertise in the relevant specialty/medical discipline for the service being requested;
  • Requires prior authorizations to be valid for an entire course of approved treatment and through a 90-day transition period if an enrollee undergoing treatment switches to a new MA plan;
  • Strengthens behavioral health network adequacy requirements for MA plans.  (Andrew Busz,


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