CMS Issues FAQ Memo Related to CY 2024 MA Final Rule

CMS on  April 5, 2023 issued the “Medicare Program; Contract Year 2024 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicare Cost Plan Program, and Programs of All-Inclusive Care for the Elderly” final rule which included requirements and clarifications relating to Medicare Advantage coverage criteria for basic benefits, use of prior authorization, and the annual review of utilization management tools. The new regulatory provisions are applicable to coverage beginning Jan. 1, 2024.

Since the issuance of this rule, CMS has received questions about the application of these rules once they are effective. In this memo, CMS provides clarification about how the agency expects MA plans to comply with these new rules. This memo covers questions related to use of internal coverage criteria, the "two-midnight rule," post-claim audits, prior authorization, and utilization management requirements. Members are encouraged to monitor MA plan compliance and report as necessary.