CMS Pauses Enforcement of Health Equity Requirements in Medicare Advantage Plans
Relevant to: Utilization Management
Each week, we scan the latest CMS memos to find the most important ones that apply for PACE programs. Below is a summary of what you need to know.
Disclaimer: The content provided on this site is a summary for informational purposes only, and Grane PBM, Inc. assumes no liability for any errors or omissions in the site’s content. The information does not constitute legal or regulatory advice or replace the original CMS memo. Readers are advised to consult the CMS memo in its entirety and to verify information independently before making any decisions based on this information.
Click here to read the complete memo from CMS.
Introduction
The Centers for Medicare & Medicaid Services (CMS) has decided to temporarily pause enforcement of specific requirements for Medicare Advantage Organizations. This move affects regulations mandating the inclusion of health equity experts on utilization management committees and the annual health equity analysis of prior authorization practices. The decision allows CMS time to reevaluate these regulations and consider potential changes through future rulemaking, with the suspension lasting until further notice.
Key Dates and Deadlines
Based on the memo provided, here are the important dates:
- Enforcement discretion decision date: June 16, 2025
- Original requirement for UM committees to include a health equity expert: January 1, 2025
- Original deadline for posting health equity analysis results: July 1, 2025
- Requirement to report prior authorization metrics is still in effect starting: 2026
Description: CMS is suspending the enforcement of certain requirements effective immediately until further notice.
PACE Compliance
This memo is relevant to PACE programs because it addresses enforcement discretion on requirements that were intended to ensure inclusivity and equity in care provided through Medicare Advantage Organizations. Although PACE programs operate somewhat differently from Medicare Advantage plans, the emphasis on health equity is pertinent across all health service programs.
While the enforcement of requirements to ensure expertise in health equity and conduct health equity analyses is suspended, PACE programs should be aware of possible forthcoming changes and continue to prioritize equitable care practices. During the suspension period, affected organizations, like MAOs, may continue with voluntary compliance to keep aligning with the intended goals of the regulations to foster an inclusive healthcare environment.
PACE organizations should continue to monitor any updates regarding the suspension and potential rulemaking that might impact similar processes within their programs. Maintaining transparency with beneficiaries regarding service access and outcomes would be advisable during this period of regulatory re-evaluation. Furthermore, PACE programs should consider engaging with any formal rulemaking processes when opportunities for public comment arise, to ensure their operations are aligned with anticipated regulatory changes.
Required Actions
1. Note the suspension of enforcement for the UM committee’s requirement to include a health equity expert, and adjust any planning or staffing efforts accordingly.
2. Suspend activities related to conducting and publicly posting the results of the annual health equity analysis as previously required.
3. Remain informed and prepared for potential regulatory changes through formal rulemaking and continue to comply with the requirement to report prior authorization metrics from 2026.
FAQs
- “What is the purpose of the temporary suspension of enforcement by CMS?”
- “Which specific requirements are affected by this CMS enforcement discretion?”
- “How long will the suspension of these CMS requirements be in effect?”
- “Will CMS make any permanent changes to regulations related to health equity analysis?”
