Medicare Regulatory Compliance Updates
There were several updates to the Medicare regulatory landscape this past quarter, and to help keep you informed, we’ve summarized a few of the more significant ones here:
NAIC Formal Inquiries for Guidance
On September 25, 2024, the National Association of Insurance Commissioners (NAIC) sent two formal letters.
The first letter was to the Office of Civil Rights, U.S. Department of Health and Human Services, regarding Section 1557 of the ACA and the application of Non-Discrimination Rules to Medigap. NAIC is requesting further enforcement guidance, including answers to the following:
Role of state regulators in enforcement
Need for review and approval of rates and plans by states prior to use
Applicability to Medicare Supplement (age rating, age or disease coverage restrictions, etc)
Preemption of state laws
Applicability to STLDI and Excepted Benefit plans
The second letter was to the Centers for Medicare & Medicaid Services (CMS), regarding provider withdrawals from Medicare Advantage plans and the subsequent Special Enrollment Period (SEP) to return to traditional Medicare or Medicare Supplement. NAIC is requesting further enforcement guidance, including answers to the following:
SEP determination criteria
Notification and communication process between plans, regulators and affected beneficiaries
Role of state regulators in enforcement
Continuity of care protections
Medigap plan availability during guarantee issue
Minnesota OE Effective Date Change
Minnesota’s Governor approved SF 4097, which changes the effective date of the 2023 Omnibus Bill, chapter 57, Article 2, Sections 7-15 (SF 2744), from 8/1/2025 to 8/1/2026. SF 2744 introduces an OE period, prohibits pre-existing condition limitations, and adds a guaranteed issue situation. Check out our previous blog to learn more.
CMS Final Rules
CMS has been busy over the past quarter providing final rules and notices for the Medicare Program effective January 1, 2025.
Medicare Program; CY 2025 Inpatient Hospital Deductible and Hospital and Extended Care Services Coinsurance Amounts (CMS-8086-N)
Calendar Year 2025 Part A Premiums for the Uninsured Aged and for Certain Disabled Individuals Who Have Exhausted Other Entitlement (CMS-8087-N)
Medicare Part B Monthly Actuarial Rates, Premium Rates, and Annual Deductible Beginning January 1, 2025 (CMS-8088-N)
Medicare Program; End-Stage Renal Disease Prospective Payment System, Payment for Renal Dialysis Services Furnished to Individuals With Acute Kidney Injury, Conditions for Coverage for End-Stage Renal Disease Facilities, End-Stage Renal Disease Quality Incentive Program, and End-Stage Renal Disease Treatment Choices Model (CMS-1805-F)
Medicare Drug Price Negotiation Program: Final Guidance, Implementation of Sections 1191 – 1198 of the Social Security Act for Initial Price Applicability Year 2027 and Manufacturer Effectuation of the Maximum Fair Price in 2026 and 2027 (CMS-1800-N4)
Medicare Program; Calendar Year (CY) 2025 Home Health Prospective Payment System (HH PPS) Rate Update; HH Quality Reporting Program Requirements; HH Value-Based Purchasing Expanded Model Requirements; Home Intravenous Immune Globulin (IVIG) Items and Services Rate Update; and Other Medicare Policies (CMS-1803-F)
CMS also has released the following unpublished, final rules that will be effective January 1, 2025.
Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems; Quality Reporting Programs, including the Hospital Inpatient Quality Reporting Program, etc. (CMS-1809-FC)
Medicare and Medicaid Programs: Calendar Year 2025 Payment Policies under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies; Medicare Shared Savings Program Requirements; Medicare Prescription Drug Inflation Rebate Program; Medicare Overpayments (CMS-1807-F and CMS-4201-F5)
Additionally, CMS released the "Medicare and You" handbook for 2025
Exciting News!
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Telos Actuarial’s team of experienced regulatory compliance professionals can help you navigate and submit these reports, keeping you in compliance.
Reach out to compliance@telosactuarial.com to learn more about the Compliance services we provide!
