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Medicare Advantage benefits expansion could help patients, physicians

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AMGA weighs in on policy changes proposed for 2025.

medicare advantage concept: © wladimir1804 - stock.adobe.com

© wladimir1804 - stock.adobe.com

Expanding benefits in Medicare Advantage could help patients, physicians and other health providers, according to AMGA.

The association endorsed some policy and technical changes proposed for 2025 for MA, also known as Medicare Part C, and the Medicare Prescription Drug Benefit Program (Medicare Part D). The U.S. Centers for Medicare & Medicaid Services published the changes with a public comment period at the end of 2023.

“Addressing the holistic needs of chronically ill patients, including social drivers that influence health outcomes, is critical to their overall well-being,” AMGA President and CEO Jerry Penso, MD, MBA, said in a news release. “Ensuring patients are aware of what services are available will help them get the most out of their coverage and benefits.”

AMGA proffered its recommendations on proposed changes dealing with behavorial health access, Special Supplemental Benefits for the Chronically Ill (SSBCI), social drivers of health, and more.

Behavioral health

CMS could add “Outpatient Behavioral Health” to the facility types evaluated in its network adequacy reviews. AMGA said it would encompass opioid treatment providers, marriage and family therapists, mental health counselors, addiction medicine and behavioral health providers.

Doing so “would help increase access to valuable behavioral health services,” AMGA said. While access via telehealth is important, AMGA said MP plan networks should reflect the importance of in-person care for patients.

SSBCI

SSBCI offers nonmedical benefits intended to maintain or improve beneficiaries’ health or overall function, over time. AMGA supports CMS’ proposal to change the standard for qualification as an SSBCI. In the new standard, plans would need assemble bibliographies of studies or data demonstrating effectiveness of an SSBCI and make the information available to CMS upon request.

“The proposed rule acknowledges the substantial increase in both the number and scope of SSBCI offered by MA plans since their introduction,” the AMGA letter said. “AMGA applauds this trend, noting that plans are now addressing a variety of nonmedical needs that significantly impact beneficiaries’ health, and supports CMS' proposal to help ensure that SSBCI improve or maintain beneficiary health.”

Prior authorizations

Prior authorizations (PA) have a disproportionate effect on underserved communities, according to AMGA.

CMS is proposing to use committees evaluating PA policies and procedures from a health equity lens. But that may not adequately affect PA and, when possible, PA should be eliminated, not just reformed, according to AMGA.

“While AMGA does not object to the proposed committee reforms, we advocate for expedited approvals to alleviate the burden of overly restrictive PA policies on communities and beneficiaries,” the letter said.

Appeals fast-track

The association supported equal access to a fast-track appeals process for MA beneficiaries. Quality improvement organizations should review “untimely fast-track appeals regarding termination of services provided in home health agencies, comprehensive outpatient rehabilitation facilities, or skilled nursing facilities,” AMGA said. Current regulations have different appeals processes for MA and traditional Medicare.

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