ARTICLE SUMMARY:
CMS recently finalized a regulation holding Medicare Advantage plans to stricter standards for how they set coverage policies and wield prior authorization powers. Here are six takeaways from the rule linked to medtech priorities on the issue.
The impact of the Medicare Advantage (MA) program on medtech adoption is growing as the proportion of Medicare-eligible beneficiaries enrolling in private payor-administered MA plans expands. That trend has put the relative lack of transparency about MA coverage policies compared with traditional Medicare, and the frequent use of prior authorization by MA plans as a cost-control mechanism, increasingly on device firms’ radars.
As a result, a proposed rule CMS issued in December to tighten the reins on MA plans attracted vocal support from the device sector, along with requests for the agency to go even further to prevent discrepancies between traditional Medicare and MA. Now, the final rule is out, and, on the one hand, CMS has largely stuck to its plan, despite some resistance from the private insurers that administer Medicare Advantage plans. On the other hand, the agency has decided not to follow through on many of the requests from medtech groups for additional mandates on MA plans beyond what was proposed late last year. For more context on the industry’s asks, check out our earlier coverage of the proposed rule. (See “Industry Pushes CMS on Medicare Advantage Accountability Proposals,” Market Pathways, March 27, 2023.) Here are six takeaways from the final regulation, from which the relevant provisions take effect next January 1.
