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Earlier this year, CMS announced a new final rule “Star Ratings, marketing and communications, health equity, provider directories, coverage criteria, prior authorization, network adequacy, and other programmatic areas.”

The full press release from CMS regarding this final rule can be found at this link.

It’s a lengthy release that details what goals CMS had in implementing this rule: protecting beneficiaries, strengthening the star rating program, encouraging equity in health care, and increasing access to behavioral health care for MA recipients.

However, there are many other consumer protections being implemented, some of which may require you to adjust your marketing efforts.

What This New Final Rule Means for Agents

  • CMS Logos & ID Cards: In an effort to prevent “misleading” marketing, CMS will restrict the use of the Medicare logo, Medicare name, and Medicare ID Card image. All Medicare ID Card images must be approved by CMS prior to use.
  • Marketing Activities Following an Educational Event: You may not hold a marketing event within 12 hours of holding an educational event in that location. The term “location” covers not only the building where the educational event was held but also adjacent buildings.
  • 48-Hour Delay on Scope of Appointment: A 48-hour waiting period is now required between obtaining an SOA and beginning a marketing appointment. This waiting period is waived for walk-in meetings at your office, kiosk or other walk-in meeting location, as well as for situations where the client is within four days of the end of an election period. Client-initiated calls can be immediate. 
  • Updates to the Third-Party Marketing Organization Disclaimer: The new TPMO disclaimer reads as follows,

    “We do not offer every plan available in your area. Currently we represent [insert number of organizations] organizations which offer [insert number of plans] products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.”

  • Approval Required for all Materials Mentioning Benefits Starting July 10: In a memo released on May 10, 2023, CMS widened the definition of marketing to include “any material or activity that is distributed via any means (e.g., mailing, television, social media, etc.) that mentions any benefit.”

    This new definition means that any marketing materials you release that mention benefits must be submitted and approved through HPMS.

While these latest updates from CMS may require some adjustments in your marketing tactics, they’re manageable, particularly with the right support. The NCC Team is ready to help you navigate any questions you may have about marketing Medicare under these updated guidelines.

Keep reading below for a deeper dive into some of what motivated this new Final Rule, or give us a call at 800-695-0280 to discuss your marketing success in detail.

Why is CMS Doing This Now?

The CMS press release refers to a prior report by the U.S. Department of Health and Human Services. The report, released in 2022, was titled, “Some Medicare Advantage Organization Denials of Prior Authorization Requests Raise Concerns About Beneficiary Access to Medically Necessary Care.”

The full report is worth the read, but the short version is that the study found that beneficiaries enrolled in MA plans were often not receiving the level of care they were entitled to, specifically related to procedures requiring prior approval.

From the report:

“Our case file reviews determined that MAOs sometimes delayed or denied Medicare Advantage beneficiaries’ access to services, even though the requests met Medicare coverage rules. MAOs also denied payments to providers for some services that met both Medicare coverage rules and MAO billing rules.”

The release mentions issues with pre-approved service in particular, stating:

“CMS has received numerous inquiries regarding the use of prior authorization by Medicare Advantage plans and the effect on beneficiary access to care. In the rule, CMS finalizes impactful changes to address these concerns and to advance timely access to medically necessary care for enrollees.”

In general, the rule means that CMS will be applying more oversight to MA plans and the coverage beneficiaries receive under these plans.

“In the final rule, CMS more clearly defines when applicable Medicare coverage criteria are not fully established by explicitly stating the circumstances under which MA plans may apply internal coverage criteria when making medical necessity decisions.”

While there are numerous individual provisions in this Final Rule, the broad intent seems to be to create more parity between Original Medicare coverage and the care beneficiaries receive from private Medicare Advantage plans. For example, CMS believes that if Original Medicare covers a procedure, then a private MA plan should cover it as well.

What This Means for Your Clients

If this final rule is implemented as stated, then MA planholders should no longer be rejected or charged for care that would otherwise be covered under Original Medicare. Ideally, you will be able to feel even more confident in the coverage you are offering them.

Have more questions about this final rule, or anything else related to Medicare sales? Call us at 800-695-0280 and let our support team guide you to success.

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Aetna is an American managed health care company that provides traditional and consumer-directed health care insurance and related services, such as medical, pharmaceutical, dental, behavioral health, long-term care, and disability plans, primarily through employer-paid insurance and benefit programs1. Aetna is a proud CVS Health company and shares a common purpose with CVS Health: bringing their heart to every moment of your health. Aetna believes that everyone should have a fair and just opportunity to achieve their best health, which is known as health equity. Aetna is committed to improving the environment, addressing health inequalities, investing in people’s health, acting with integrity and protecting against health care fraud and abuse.

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