New Medicare Advantage Rules Aim to Improve Access, Equity
By Emma Freer


Medicare Advantage enrollees soon may benefit from expanded access to outpatient behavioral health care and more equitable prior authorization policies.

The Centers for Medicare & Medicaid Services (CMS) recently issued final rules that impact Medicare Advantage (Part C) and Medicare prescription drug benefits (Part D), among other programs, citing a desire “to promote competition, increase access to care, including important behavioral health services, and protect individuals from inappropriate marketing and prior authorization,” according to an April 4 press release.

The rules take effect June 3.

The Texas Medical Association is closely tracking the regulatory changes, including the addition of network adequacy standards for a new category, “outpatient behavioral health,” in which setting marriage and family therapists, mental health counselors, addiction medicine physicians, and other behavioral health practitioners may provide services covered by Medicare.

The new rules also require Medicare Advantage plans to update their prior authorization policies and procedures in an effort to reduce disparities among underserved patient populations.

Specifically, plans' relevant utilization management committees must:

  • Include at least one member with an expertise in health equity;
  • Conduct an annual analysis of the plan’s prior authorization policies and procedures; and
  • Make public the results of such analyses.

Together, these requirements aim to “identify any disproportionate delay or denial of access to needed care for enrollees who have a disability or limited income and resources,” according to the press release.

For more information about the rules, check out CMS’ dedicated fact sheet. And for assistance related to insurance payments, check out TMA’s free Physician Payment Resource Center.

Last Updated On

May 15, 2024

Originally Published On

May 15, 2024

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Emma Freer

Associate Editor

(512) 370-1383

Emma Freer is a reporter for Texas Medicine. She previously worked in local news, covering city politics, economic development, and public health. A native Clevelander, she graduated from Columbia Journalism School and the University of St. Andrews.

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