new rule (RIN: 0938-AU96)
Recently, the Centers for Medicare and Medicaid Services (CMS) proposed a new rule that would revise regulations on certain aspects of Medicare plans, including Medicare Advantage (Part C) plans. One of the most significant changes to these regulations would require carriers to have more accessible information for underserved and marginalized populations. CMS aims to promote and advance health equity across the country’s diverse population.
The benefits of Medicare Advantage plans are often debated, with people having strong opinions on one side or the other. However, certain statistics prove that regardless of personal opinions, there are improvements to be made in access to care across all Medicare Advantage plans. For example, according to a study done by the Kaiser Family Foundation, more than two million prior authorization requests were partially or fully denied by carriers in 2021. Of those, only 11% were appealed. Most appeals resulted in a partial or complete overturn of the initial denial.
These numbers raise concerns about how many of the initial requests should have been approved. It is difficult to determine why so few enrollees chose to appeal a denial. Still, there is no argument that Medicare includes highly technical language that may have affected the low appeal rate. CMS’s proposed rule addresses issues like this and includes methods for increasing health equity and communication across cultures.
major provisions regarding health equity
There are a total of 11 provisions in the proposed rule. The revisions relate to medication therapy management, Star Ratings, marketing and communications, provider directories, health equity, prior authorization, coverage criteria, network adequacy, passive enrollment, formulary changes, and overpayments. Many of the provisions are greatly concerned with accessibility and health equity across our diverse society.
marketing communication materials
CMS already requires Medicare Advantage plan sponsors to translate materials into any language required by at least 5% of individuals within a service area. However, CMS found that enrollees must often make multiple requests each time they need plan material in a non-English language. In addition, an increasing number of dual-eligible individuals have a plan that includes both Medicare and Medicaid. Sometimes, the Medicaid translation requirements do not match the Medicare Advantage translation requirements.
To rectify these issues, CMS proposes that all plan materials are provided on a standing basis in any language that at least 5% of individuals within the service area require.
individualized care plans
Medicare Advantage has a subset of plans called Special Needs Plans (SNPs). These plans cater to a specific group of people: dual-eligible (D-SNP), chronic condition (C-SNP), and institutionalized (I-SNP). Every SNP must include an individualized care plan (ICP) based on that person’s unique needs. Currently, ICPs are not always translated into the enrollee’s preferred language, even after expressing a preference for translation during their health risk assessment.
The proposed rule would ensure each enrollee had access to every document, including their ICP, in their preferred language. In addition, any auxiliary aids or services would be provided to the enrollee to encourage further health equity.
medicare advantage provider directories
Provider directories are important to Medicare Advantage plans as they rely on contracted providers to administer the plans. An enrollee who received care outside their provider network will pay higher fees or have no coverage whatsoever. Therefore, the accuracy of provider directories is crucial.
CMS requires a long list of provider and office information to be included in the directory. Currently, no regulation requires providers to list non-English languages spoken or accessibility options for those with physical disabilities. The new proposed rule would require providers to include their cultural and linguistic capabilities, including languages spoken.
equitable access to medicare advantage services
Current regulations require Medicare Advantage plan sponsors to provide services in a culturally competent manner. This includes addressing unique ethnic and racially-related health care concerns. As these rules are already in place, CMS is only proposing an update to ensure broad protections are in place to minimize discriminatory barriers as the population becomes even more diverse. “Equitable access” is a term used to describe the quality of care to the entire population; it does not aim to address one group over another.
telehealth and digital literacy
Telehealth services became increasingly popular during the COVID-19 pandemic. Many individuals found telehealth convenient, especially when it eliminated the need for travel. As a result, telehealth services are still prevalent today. However, there is evidence of access disparities due to low digital literacy, especially among groups who already experience other forms of health inequity. This is concerning for Medicare Advantage plan carriers as the majority of their enrollees are 65 years old or older.
In the proposed rule, CMS wants to address the issue by requiring Medicare Advantage plans to offer digital literacy education so enrollees can access medically-necessary telehealth benefits. Doing so would address another area of health inequity among Medicare beneficiaries, allowing them to access more care and education.
quality improvement programs
Quality Improvement (QI) programs help ensure plans remain valuable to enrollees. CMS proposes to develop strategies within the QI programs to reduce disparities in health care and advance health equity among the Medicare population. The rule would require Medicare Advantage plans to incorporate activities that support those efforts. Activities include improving communication, hiring bilingual staff, using culturally and linguistically appropriate materials, and participating in community outreach.
concerns for medicare advantage plan carriers
What does all these mean for Medicare Advantage plan carriers? Carriers who have not already adopted a strong cultural competency and inclusion model will need to develop strategies and implementation plans to ensure all members have access to plan information, education, and care. This includes (but is not limited to) the translation of plan materials into many different languages, providing auxiliary aids and supports, updates to their provider information on various healthcare websites, and new education and resources for members.
Insurance carriers will also need to implement processes to translate more customized aspects of plan material. For example, while insurance carriers have non-English versions of their notices readily available, more variable information is often not translated. We find this to be true in regard to the prior authorization denials mentioned in the introduction. The variable information, such as the reason for the denial, is usually kept in English, despite the rest of the notice being in the enrollee’s preferred language. This factors into the low appeal rate and, thereby, the inability of non-English speakers to receive the care they need.
CQ fluency’s turnkey translation solutions
CQ fluency is known for our expertise in translation services and cultural competency training. We can help carriers comply with mandated QI programs and build stronger relationships with their multicultural client population. Services include:
- translating customized care plans and prior authorizations
- improving multicultural customer service
- testing proficiency of bilingual teams
- monitoring multilingual call centers
- providing auxiliary aids and services such as braille