Medicare Advantage FAQ

The Centers for Medicare & Medicaid Services recently sent a memo to Medicare Advantage (MA) organizations and Medicare-Medicaid plans that provides additional information on the coverage criteria for basic benefits, the use of prior authorization, and review of utilization management tools. The FAQ was developed for the Contract Year 2024 final rule policies and procedures that were effective January 1st. 

Highlights of the Frequently Asked Questions memo include the following: 

• Artificial intelligence (AI) and algorithm software may be used to “assist MA plans in making coverage determinations,” but the agency has stated that the MA plan must ensure that the data used in that AI assistance comply with the rules and regulations for making said determinations. MA plans cannot rely solely on AI for decision-making. 
• MA plans must make medical necessary determinations using the medical history, physician recommendations and clinical notes of each patient, and importantly, the criteria used to make a coverage determination must meet Traditional Medicare coverage criteria. Medicare coverage criteria include applicable Medicare statutes, National Coverage Determinations and Local Coverage Determinations. 
• If there is not established Medicare coverage, then MA plans may use coverage criteria based on current evidence in treatment guidelines, or clinical literature, and that information must be made available on the MA plan website. 
• CMS has clarified the definitions of widely used treatment guidelines and clinical literature to ensure that MA plans are meeting coverage standards acceptable to Traditional Medicare.
  • “Widely used treatment guidelines are those developed by organizations representing clinical medical specialties and refer to guidelines for the treatment of specific diseases or conditions.” 
  • “Acceptable clinical literature includes large, randomized controlled trials or prospective cohort studies with clear results, published in a peer-reviewed journal, and specifically designed to answer the relevant clinical question, or large systematic reviews or meta-analysis summarizing the literature of the specific clinical question.” 

The FAQ document provides additional information on topics such as post-acute care, the two-midnight rule, and post-claim reviews.