Medicare Advantage insurers are already finding ways to skirt new federal regulations designed to ease beneficiary access to medical care, according to the American Hospital Association and the Federation of American Hospitals.
In April, the Centers for Medicare and Medicaid Services published a final rule that, among other things, requires Medicare Advantage plans to cover the same services as fee-for-service Medicare, with limited exceptions. Citing a notice UnitedHealthcare sent hospitals Oct. 30 outlining its coverage policies for 2024, however, the hospital trade groups says insurers are not complying and continue to set higher bars for coverage than the regulation allows.
UnitedHealthcare explains in its coverage summary that it will employ criteria that "supplement" Medicare guidelines next year. These company policies follow the law, a UnitedHealthcare spokesperson wrote in an email Wednesday. CMS declined to comment on the hospital groups' complaints.
"We are deeply concerned that these practices will result in the maintenance of the status quo where [Medicare Advantage organizations] apply their own coverage criteria that is more restrictive than traditional Medicare, proliferating the very behavior that CMS sought to address in the final rule," AHA Senior Vice President for Public Policy Analysis and Development Ashley Thompson wrote Center for Medicare Director Dr. Meena Seshamani on Monday.
AHA members are reporting that Medicare Advantage carriers are continuing to impose stricter coverage criteria and informing hospitals that they won't modify their utilization management tools or how they evaluate inpatient admissions, Thompson wrote.
The UnitedHealthcare notice "blatantly violates Medicare’s revised coverage criteria for inpatient hospital care" and is a "test case" for CMS, Federation of American Hospitals President and CEO Chip Kahn said in a news release Monday.
“FAH believes CMS actions taken earlier this year to protect seniors from abusive behavior by Medicare Advantage plans are mission critical," Kahn said "However, CMS actions only work if MA plans follow the law and if CMS enforces it by promptly addressing plan violations," he said.
The UnitedHealthcare spokesperson wrote that the “American Hospital Association and Federation of American Hospitals are advocating a position that is inconsistent with language in the CMS final rule for 2024. Our Medicare Advantage hospital, emergency and ambulance services coverage policy complies with CMS final rule."
The health insurance trade association AHIP did not respond to a request for comment.