CMS issued a final rule in April that introduced new requirements concerning coverage criteria and the use of utilization management (UM) requirements in the Medicare Advantage program. The rule also clarified coverage criteria for basic benefits, added continuity of care requirements, and mandated an annual review of UM tools. These coverage regulations will come into effect from January 1, 2024.
To ensure the understanding and implementation of coverage criteria and UM requirements, CMS will conduct strategic conversations with Medicare Advantage organizations starting from November 2023.
From January 2024, the Medicare Parts C and D Oversight and Enforcement Group will commence conducting routine and focused audits of organizations to assess their compliance with UM requirements. Routine program audits will be carried out as they have been in the past. Focused audits will be limited in scope and duration.
Organizations offering Medicare Advantage and Medicare Advantage-Prescription Drug Plans may be subject to focused audits even if they completed a routine program audit in 2021 or 2022. Additionally, organizations audited in 2023 and undergoing a CMS-led audit validation may also have their UM requirements reviewed during the validation audit.
If you have any questions about the strategic conversations, please contact your assigned CMS account manager. For questions about the 2024 focused audits, please send an email to part_c_part_d_audit@cms.hhs.gov.
