January 8, 2024

On January 5, APMA submitted comments to CMS Policy and Technical Changes to the Medicare Advantage and Medicare Prescription Drug Benefit Programs Proposed Rule, and in particular to respond to the proposed rule referenced above addressing supplemental benefits for the chronically ill and prior authorization.

Special Supplemental Benefits for the Chronically Ill (SSBCI) 

CMS proposes that plans must demonstrate through acceptable evidence that an item or service included as SSBCI in its bid has a reasonable expectation of improving or maintaining the health or overall function of a chronically ill enrollee. APMA believes that it is critical that Medicare beneficiaries be marketed programs that are best suited to improve their health, including their foot and ankle health, and promoted inclusion of comprehensive diabetic lower extremity exam (CDLEE) and diabetic foot counseling, as ideal candidates for inclusion as SSBCI.

Utilization Management and Prior Authorization

As part of its overall efforts to address health equity, CMS proposes to require that beginning January 1, 2025, MA plans’ Utilization Management (UM) committees must include at least one member with expertise in health equity, that the committee must conduct an annual health equity analysis of the use of prior authorization using specific metrics, and that the report be approved by the member of the UM committee that is an expert on health equity and posted publicly on the MA plan’s website. APMA acknowledged that it is highly likely that certain underserved populations have experienced barriers to care due to policies like prior authorization, especially when these policies have been administered inefficiently. APMA asked that CMS pay particular attention to cellular and/or tissue-based products (CTPs, or skin substitute) services, in-office injections, in-office medically necessary imaging, ankle-foot orthoses (AFOs) for traumatic conditions, surgical dressings, and biopsy of suspicious lesions. APMA also recommended that CMS should consider addressing burdens related to time-sensitive items such as ultrasound for deep vein thrombosis diagnosis. APMA commented that UM tools frequently place an incredible burden on already overwhelmed providers. Specifically, prior authorization imposes significant time-consuming requirements that reduce clinicians’ time and ability to focus on delivering high-quality care.

You can read the letter in its entirety at www.apma.org/comments. Follow the APMA Weekly Focus and other APMA publications to keep up to date on APMA’s advocacy activities.

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