Relevant to: MAOs
On April 12, 2023, CMS issued a final rule (CMS-4201-F) that included new requirements about coverage criteria and the use of utilization management (UM) requirements in the Medicare Advantage (MA) program. CMS clarified coverage criteria for basic benefits and the use of prior authorization, added continuity of care requirements, and required an annual review of UM tools.
The regulations are applicable to coverage beginning January 1, 2024. This memorandum provides important information to Medicare Advantage Organizations (MAOs) regarding CMS’s oversight of these provisions.