The Centers for Medicare & Medicaid Services (CMS) is now reviewing public comments to its proposed 2025 Medicare Advantage final rule which included a new provision which would enhance Enrollees' Right To Appeal a Medicare Advantage (MA) Plan's Decision To Terminate Coverage for Non-Hospital Provider Services. The proposed appeals process would apply to Skilled Nursing Facility (SNF), Home Health or comprehensive outpatient rehabilitation facility (CORF). Mass Senior Care and AHCA strongly support CMS’s proposed modified appeals provision to ensure that individuals in a Medicare Advantage plan have access to high quality care and timely, medically necessary services. Under the proposed modification, beneficiaries enrolled in Traditional Medicare and MA plans have the right to a fast-track appeal by an Independent Review Entity (IRE) when their covered skilled nursing facility (SNF), home health, or comprehensive outpatient rehabilitation facility (CORF) services are being terminated. Currently, Quality Improvement Organizations (QIO) act as the IRE and conduct these reviews. Under current regulations, MA enrollees do not have the same access to QIO review of a fast-track appeal as Traditional Medicare beneficiaries. CMS is proposing to (1) require the QIO, instead of the MA plan, to review untimely fast-track appeals of an MA plan's decision to terminate services in an HHA, CORF, or SNF; and (2) fully eliminate provision requiring the forfeiture of an enrollee's right to appeal a termination of services decision when they leave the facility. These proposals would bring MA regulations in line with the parallel reviews available to beneficiaries in Traditional Medicare and expand the rights of MA beneficiaries to access the fast-track appeals process.
The CMS proposal comes in response to Congressional scrutiny of MA Plans use of artificial intelligence and other technology to influence, and possibly dictate, coverage and the length of patient stays.
For more information on the proposed rule, please see CMS fact sheet.