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Medicare Advantage might be in for some changes

On Behalf of | Oct 24, 2022 | CMS Conditions of Participation

CMS has proposed several changes to the regulations that govern Medicare Advantage. Some of the changes affect Medicare Advantage or MA plans in particular, so you’ll want to be aware of how CMS’s proposed changes might come into play for you in Texas.

What does CMS want to change about Medicare Advantage regulations?

The changes that CMS has proposed include:

  • Network adequacy
  • Beneficiary access
  • MLR reporting
  • MOOP

These proposed rule changes were announced by the Centers for Medicare & Medicaid Services with a full explanation of the alterations posted on their website. This branch of the Department of Health and Human Services or HHS is responsible for providing coverage to millions of people through programs like Medicare Advantage.

A breakdown of the proposed changes

The first proposal set forth by CMS is to expand on service area applicants. CMS proposed additional requirements for services area applicants in the way they submit their applications. This would include requiring the submission of the contracted networks they have proposed from the start.

The second proposition that CMS has made intends to provide some clarification into whether or not beneficiary access requirements apply during an emergency or disaster. Specifically, this proposition would answer the question as to whether or not these rules apply in the event that health care has become inaccessible. This proposition would clarify definitively that they do.

Thirdly, CMS proposes that they go back to MLR reporting requirements. This stands for medical loss ratio and was the system they used from 2014 to 2017.

And the fourth proposition made by CMS relates to beneficiaries who are dually eligible. This change would adjust the way that the MOOP limit is determined for these individuals. The MOOP limit refers to your maximum out-of-pocket expenses – the most you’ll have to pay with your own money.