CMS FINAL RULE 4201-F: What to Know

At tango, we know that high-quality home health care services are essential to ensuring optimized post-acute outcomes. In an ever-evolving industry such as healthcare, there are many challenges and changes that companies across the healthcare continuum face in order to ensure everyone can receive access to consistent, timely, and elevated quality of care. These include rate cuts, access issues, and regulatory changes from the Center for Medicare & Medicaid Services (CMS).

This past April, CMS issued Final Rule 4201-F that went into effect as early as June and will continue to have various effective dates for contract years 2024 through 2027. While changes and additional amendments to regulations are not uncommon, these adaptations are important to note within the home health care space and industry at large. Since these CMS policies are aimed at ensuring that beneficiaries have consistent and timely access to medically necessary care, it is important to understand a broader scope of impact across the health care network.

Here, we breakdown 4 of CMS’ recent adjustments in their efforts to increase oversight of Medicare Advantage (MA) plans to further align with traditional Medicare coverage and what that means across the health care service provider network as they begin to take shape into 2024.

Ensuring Timely Access to Care

The Final Rule outlines requirements for utilization management (UM) regarding patient coverage and the practice of prior authorization. New guidelines ensure people with MA plans receive access to the same medically necessary care they would receive in Traditional Medicare. Prior authorization policies are used to confirm presence of diagnosis and to ensure a service is medically necessary. If a beneficiary is undergoing an active course of treatment and switches from traditional Medicare to an MA plan or switches to a new MA plan, the plan will provide a minimum of a 90-day transition period to avoid disruption in care. Such changes will strive to ensure that consistent care is accessible to patients no matter the status of their MA plans.

Protecting Beneficiaries

New measures to protect beneficiaries include the establishment of a Utilization Management Committee to review policies on an annual basis and ensure consistency with Traditional Medicare’s NCDs, LCDs, and guidelines. Aside from UM practices, another protection measure will include countermeasures for misleading marketing practices targeting patients. Moreover, these changes are in-line with efforts to increase transparency and the understanding beneficiaries have relating to their plans and coverage. Notification requirements to beneficiaries means that if a contracted participating provider contract is termed, a good faith effort of at least 30 days’ notice before effective term date is done for the members seen on a regular basis by the terming provider.

Advancing Health Equity

In order to advance best practices concerning health care, the Final Rule will soon begin to require Medicare Advantage organizations to include more substantial cultural and linguistic capabilities within their service directories. Cultural competence on behalf of health care providers is increasingly important to guaranteeing all patients accessibility to the highest quality of care. Reducing health disparities to MA enrollees will actively work to increase communication across health care and further guarantee standardization of care practices.

Improving Access to Behavioral Health

Another aspect of this Final Rule is increasing MA organizational responsibilities to provide adequate behavioral health services within network. While there are many specific new requirements, one to note will require MA organizations to establish programs of care coordination involving community, social, and behavioral health services to mirror levels of accessibility similar to acute care for all enrollees.

New additions and changes to CMS regulations are top of mind for many stakeholders within the home health care industry. At tango, our Chief Compliance Officer, Kimberly Templeton-Garcia B.S.N., CRNI, CHC , has been following the 2023 Medicare Advantage CMS 4201-F changes closely. Kim acknowledged the commitment to evaluating these changes across industry stakeholders, and regarding the Final Rule, that “at tango, we are working with our health plan and provider partners closely to monitor the full impact”.

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