ASNC to CMS: Strengthen Coverage, Utilization Management Rules for Medicare Advantage Plans

In a letter submitted last week, ASNC asked the Centers for Medicare & Medicaid Services (CMS) to finalize several proposals that would make it harder for Medicare Advantage (MA) plans to use certain internal coverage criteria or policies and guidelines when making coverage decisions.

Background: In April 2023, CMS put guardrails in place limiting when MA plans may develop and use internal coverage criteria to achieve better alignment with traditional Medicare coverage. Since then, but still under the Biden administration, CMS determined those regulations needed to be strengthened.

CMS proposed to redefine internal coverage criteria as “any policies, measures, tools, or guidelines, whether developed by an MA organization or a third party, that are not expressly stated in applicable statutes, regulations, NCDs, LCDs, or CMS manuals and are adopted or relied upon by an MA organization for purposes of making a medical necessity determination.” By including criteria developed by third parties in its proposed definition of internal coverage criteria, CMS was attempting to ensure that MA organizations are held responsible for coverage criteria used by medical benefit management companies, such as Evicore.

CMS proposed 2 new prohibitions on the use of internal coverage criteria:

When a criterion does not have any clinical benefit and, therefore, exists to reduce utilization of the item or service
When a criterion is used to automatically deny coverage of basic benefits without the MA organization making an individual medical necessity determination

In its letter, ASNC discussed the policies of some insurance companies that automatically deny coverage of cardiac PET and other appropriate functional stress tests for the evaluation of stable chest pain and require CCTA as a first-line test.

ASNC also voiced support for greater disclosure of prior authorization use by MA organizations, including requiring that the percentage of prior authorization denials and approvals must be reported at the item and service level, rather than in aggregate.

Next Steps: The proposed rule, including whether and how to advance CMS’s proposals, is now with the Trump administration. Stay tuned to ASNC for updates.

ASNC Comments