What’s new: As of January 1, 2024, Medicare Advantage (MA) plans are subject to new regulations governing prior authorizations and utilization management strategies.

• AHCA/NCAL, in partnership with Hooper, Lundy & Bookman, has developed a checklistto assist members providers in addressing MA denials to ensure that plans are in compliance with the new requirements. The checklist outlines items such as the appropriateness of the prior authorizations, medical necessity determinations, coverage criteria applied, denial process and provider recourse.
• AHCA/NCAL will also host a webinar on, February 27 on the topic. During the webinar, experts will review regulatory limits on these activities, focusing on new and clarified requirements for 2024.

Additional MA news: AHCA continues to advocate for MA beneficiary access to timely and medically necessary care and provider sustainability. AHCA/NCAL, as part of a coalition of other long term and post-acute care associations and the Centers for Medicare Advocacy, met with leadership from CMS on January 3 at the coalition’s request to advocate for clarity on plan compliance with the CY 2024 Medicare Advantage Final Rule.

• During the call, leaders from CMS indicated they will be strongly enforcing compliance with the new regulations through routine and focused audits of plans serving approximately 90 percent of people with MA in year one. This is an enhancement from their typical three-year audit cycle. CMS also referenced the memos sent to plans regarding their oversight activities. CMS staff invited further communication from coalition members on instances of plan non-compliance with these regulations. 

Please contact Nisha Hammel, Martin Allen, or Grant Beebe with any questions.