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CMS News | Medicare | Medicaid | 2023 | iPharmaCenter

Updated: Nov 23, 2023

November 21, 2023

Since the Opening of ACA Marketplace Coverage, 4.5 Million Selected Affordable Health Coverage

Nearly 4.6 million individuals are opting for cost-effective health plans within the ACA Marketplace during the Open Enrollment Phase.

Since the initiation of the Open Enrollment Period (OEP), 4.6 million people have selected health insurance plans through the Affordable Care Act (ACA) Health Insurance Marketplace.

Among this overall number, 20%, representing 920,000 individuals, are newcomers for the 2024 coverage period, while the remaining 80%, totalling 3.7 million, have maintained active 2023 coverage and revisited the marketplace to either renew existing plans or choose a new one for 2024.

Before the commencement of the 2024 Open Enrollment Period (OEP), around 1.5 million additional individuals enrolled in Marketplace coverage across the country from March to September 2023, in contrast to the corresponding period in 2022. This involves people who are in the phase of moving away from Medicaid coverage, as states recommence the renewal of Medicaid and Children's Health Insurance Program (CHIP) eligibility for the first time in three years after the conclusion of the COVID-19 pandemic.

The commitment of the Biden-Harris Administration to ensuring the availability and affordability of health insurance remains unwavering. The Inflation Reduction Act and the American Rescue Plan continue to play vital roles in preserving affordability.

Individuals who enrol in Marketplace coverage this year will enjoy the advantages of a highly competitive Marketplace.

For the 2024 plan year, 96% of enrollees will have the option to select from three or more plans.

Additionally, there are standardized plan choices that provide identical deductibles and cost-sharing for specific benefits. These plans share the same out-of-pocket limits as other standardized plans within the corresponding health plan category, streamlining the process for consumers to compare and make selections.

The Centers for Medicare & Medicaid Services introduced a proposed rule titled "Medicare and Medicaid Programs: Minimum Staffing Standards for Long-Term Care Facilities and Medicaid Institutional Payment Transparency Reporting" on September 1, 2023. This rule aims to establish comprehensive nurse staffing requirements for long-term care (LTC) facilities, holding them accountable for delivering safe and high-quality care to the 1.2 million residents under Medicare and Medicaid-certified LTC facilities' care daily.

CMS announced that ensuring the safety, reliability, and quality of nursing home care is a paramount objective and a top priority for CMS. The COVID-19 Public Health Emergency (PHE) had devastating consequences, leading to unprecedented illness and fatalities among nursing home residents and staff. It also exacerbated staffing issues in many facilities and highlighted disparities in care and outcomes. Despite existing regulations mandating adequate staffing levels in LTC facilities, chronic understaffing remains a significant concern.

The proposed rule comprises three key staffing provisions:

  1. Minimum Nurse Staffing Standards: These include a requirement of 0.55 hours per resident day (HPRD) for Registered Nurses (RNs) and 2.45 HPRD for Nurse Aides (NAs).

  2. 24/7 RN On-site Requirement: Facilities would be required to have an RN present on-site around the clock, seven days a week.

  3. Enhanced Facility Assessment Requirements: The rule introduces enhanced facility assessment requirements to ensure proper staffing levels.

The proposal also outlines a phased implementation approach and possible hardship exemptions for certain facilities. It represents the culmination of a multifaceted approach to determine the minimum staffing levels and types required to ensure safe and high-quality care in LTC facilities. This approach involved issuing a Request for Information (RFI) as part of the FY 2023 Skilled Nurse Facility Prospective Payment System Proposed Rule, conducting listening sessions, engaging extensively with stakeholders, driving a 2022 Nursing Home Staffing Study, and reviewing payroll-based staffing data from recent years. CMS also considered how these proposed staffing requirements would align with other ongoing CMS initiatives and programs impacting the LTC community.

Additionally, the proposed rule seeks to enhance transparency by publicizing the percentage of Medicaid payment allocated to compensation for direct care workers and support staff in nursing and intermediate care facilities for individuals with intellectual disabilities.

Furthermore, CMS has announced a national campaign to bolster staffing in nursing homes. In collaboration with the HRSA, this initiative seeks to streamline the journey for individuals interested in pursuing careers in nursing homes. Over $75 million will be invested in financial incentives such as scholarships and tuition reimbursement. This staffing campaign complements other efforts under the HHS Health Workforce Initiative, including HRSA's recent allocation of more than $100 million to expand nursing training programs and bolster the nursing workforce.

CMS published the final rule revising the Medicare Advantage (MA or Part C), Medicare Part D plan, Medicare Cost Plan, and PACE regulations regarding the Star Rating, marketing, utilization management, health equity, coverage criteria, etc.

Utilization Management Requirements

The Medicare Advantage and Part D Final Rule has outlined clinical criteria guidelines to ensure that Medicare Advantage plan members have access to medically necessary care, similar to Traditional Medicare beneficiaries. This complies with the recent recommendations from the Office of Inspector General.

The CMS has clarified the rules related to acceptable coverage criteria for basic benefits. It requires MA plans to follow national and local coverage determinations and general coverage and benefit conditions stated in Traditional Medicare regulations. In situations where coverage criteria are not established, MA organizations may create internal coverage criteria based on widely used treatment guidelines or clinical literature made available to CMS, enrollees, and providers.

The final rule simplifies prior authorization requirements, adds continuity of care requirements, and reduces disruptions for beneficiaries. According to CMS' final rule, coordinated care plan prior authorization policies can only be used to confirm the presence of diagnoses or other medical criteria and/or ensure that an item or service is medically necessary. In addition, coordinated care plans must provide a 90-day transition period when an enrollee undergoing treatment switches to a new MA plan, during which the new MA plan cannot require prior authorization for the active course of treatment.

All MA plans must set up a Utilization Management Committee to review policies annually and ensure consistency with Traditional Medicare's national and local coverage decisions and guidelines.

Marketing Requirements

The CMS has taken measures to ensure that Medicare beneficiaries are protected from misleading marketing practices and that they have access to accurate information when making coverage choices. Specifically, the CMS has prohibited ads that are generic and do not mention a specific plan name or use confusing language or imagery.

The CMS has also made changes to ensure that beneficiaries receive accurate information about Medicare coverage and are aware of how to access additional information.

Promoting Health Equity

CMS is dedicated to promoting health equity for all individuals, especially those who have been historically marginalized, underserved, and impacted by poverty and inequality. As part of this commitment, CMS is providing further clarification on existing regulations and expanding the list of populations that Medicare Advantage organizations must serve in a culturally competent manner.

Improving behavioural Health

Timely access to behavioural health services is crucial for improving the health of Medicare Advantage (MA) enrollees. The CMS has finalized policies that strengthen network adequacy requirements for MA behavioural health networks. This includes reaffirming MA organizations' responsibilities to provide behavioural health services.



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