AHA Comments on CMS Medicare Advantage and Part D Proposed Rule for Contract Year 2026

The American Hospital Association (AHA) has recently submitted comments regarding the Centers for Medicare & Medicaid Services (CMS) proposed rule for Medicare Advantage (MA) and Part D programs for Contract Year 2026. These comments are crucial for healthcare organizations, particularly those involved in Revenue Cycle Management (RCM) and medical billing services. This article explores the key points from the AHA’s comments and their implications for RCM, highlighting the need for clarity, transparency, and alignment in healthcare coverage.

Understanding the Proposed Changes

Key Areas of Focus

The proposed rule aims to enhance protections for MA beneficiaries and clarify policies for Medicare Advantage Organizations (MAOs). Key areas of focus include:

Internal Coverage Criteria
Transparency and Public Accessibility
Cost-Sharing Limits for Behavioral Health Services
Appeals and Organizational Determinations

These changes are expected to streamline processes and improve patient access to care, directly impacting RCM practices.

Internal Coverage Criteria: A Call for Clarity

The Need for Consistency

The AHA emphasizes the necessity for consistent application of internal coverage criteria by MAOs. Currently, many organizations report discrepancies in how these criteria are applied, often leading to unnecessary denials of care. According to a survey conducted by the AHA, 30% of hospitals reported experiencing increased denial rates due to unclear internal criteria used by MAOs.

Denial Reason	Percentage of Hospitals Reporting
Unclear internal criteria	30%
Lack of transparency	25%
Inconsistent application	20%
Other	25%

The AHA supports CMS’s proposed clarification that internal coverage criteria should only supplement existing Medicare coverage rules and should not create additional barriers for patients.

Implications for RCM

For billing professionals, understanding these criteria is critical. Inconsistent application can lead to increased claim denials and delayed payments. By advocating for clearer guidelines, the AHA aims to reduce administrative burdens on healthcare providers, ultimately improving cash flow for medical billing services.

Enhancing Transparency and Accessibility

Public Disclosure of Coverage Criteria

One of the most significant proposals is requiring MAOs to publicly disclose the specific criteria they use to make medical necessity determinations. This transparency is expected to improve accountability and reduce misunderstandings between providers and payers. A study from the Kaiser Family Foundation found that 40% of providers struggled to understand the criteria used by MAOs, leading to higher administrative costs.

RCM Impact

Enhanced transparency will enable RCM teams to better prepare for claims submissions. Knowing the specific criteria used by MAOs can help billing professionals ensure that claims meet the necessary requirements, thus decreasing the likelihood of denials.

Behavioral Health Services: Cost-Sharing Alignment

Aligning Cost-Sharing with Traditional Medicare

CMS proposes aligning in-network cost-sharing for behavioral health services between MA plans and Traditional Medicare. This change aims to reduce barriers to accessing mental health care, which is critical given the rising demand for such services. According to the National Institute of Mental Health, approximately 1 in 5 adults in the U.S. experience mental illness, underscoring the importance of accessible behavioral health services.

Service Type	Traditional Medicare Cost-Sharing	Proposed MA Cost-Sharing
Inpatient psychiatric services	20% coinsurance	Not to exceed 20%
Outpatient mental health treatment	20% coinsurance	Not to exceed 20%
Substance use disorder treatment	0% for opioid treatment	Not to exceed 20%

Revenue Cycle Management Benefits

For RCM, this alignment simplifies billing processes for behavioral health services. When cost-sharing is standardized, it becomes easier to communicate pricing to patients and manage collections effectively. Improved access to behavioral health services may also lead to an increase in patient volume, positively affecting revenue.

Strengthening Patient and Provider Appeal Rights

Protecting Appeal Opportunities

The proposed rule includes provisions aimed at protecting patients’ and providers’ rights to appeal adverse organizational determinations made by MA plans. This clarification is essential in ensuring that patients can contest unfavorable coverage decisions. According to AHA data, 45% of providers reported that they often face challenges in appealing such determinations.

RCM Considerations

Healthcare organizations must ensure that their billing teams are aware of these protections. Understanding patients’ rights to appeal can help RCM professionals address issues proactively, reducing the chances of write-offs due to denied claims.

Conclusion: The Path Forward for RCM

The AHA’s comments on the CMS proposed rule for Medicare Advantage and Part D programs highlight the importance of clarity, transparency, and equity in healthcare coverage. For healthcare organizations, particularly those involved in RCM and medical billing services, these changes present both challenges and opportunities.

As the healthcare landscape evolves, staying informed about regulatory changes and their implications is crucial for ensuring efficient revenue cycle processes. By aligning billing practices with the proposed changes, organizations can improve their overall financial health and better serve their patients

Additional Resources

By focusing on these key areas and adopting best practices in RCM, healthcare organizations can navigate the complexities of the evolving regulatory landscape and continue to provide high-quality care to their patients.

Frequently Asked Questions (FAQs) About AHA comments on the CMS Medicare Advantage and Part D

What are the key changes proposed by the AHA regarding Medicare Advantage and Part D for 2026?

The AHA's comments highlight several key areas of focus, including the need for clarity in internal coverage criteria, enhanced transparency and public accessibility of coverage determinations, alignment of cost-sharing for behavioral health services with Traditional Medicare, and the protection of appeal rights for patients and providers. These changes aim to improve patient access to care and reduce administrative burdens on healthcare providers.

How will the proposed changes impact Revenue Cycle Management (RCM)?

The proposed changes are expected to streamline claims submissions and reduce claim denials, which will positively impact RCM. By clarifying internal coverage criteria and enhancing transparency, billing professionals will have better guidance on submitting claims. This can lead to improved cash flow and reduced administrative costs for healthcare organizations.

What is the significance of aligning cost-sharing for behavioral health services?

Aligning cost-sharing for behavioral health services with Traditional Medicare is significant because it aims to reduce barriers to accessing mental health care. Given that approximately 1 in 5 adults in the U.S. experience mental illness, standardized cost-sharing will make it easier for patients to obtain necessary services, ultimately leading to better health outcomes and potentially increasing patient volume for healthcare providers.

What protections are being proposed for patients and providers regarding appeals?

The proposed rule includes provisions to strengthen the rights of patients and providers to appeal adverse organizational determinations made by Medicare Advantage plans. This means that patients will have clearer pathways to contest unfavorable coverage decisions, ensuring they can access the care they need and reducing the risk of write-offs for providers.

How can healthcare organizations prepare for these proposed changes?

Healthcare organizations can prepare by staying informed about the regulatory updates and the implications for their RCM practices. This includes training billing teams on the new criteria and appeal processes, ensuring they understand the importance of transparency and consistency in coverage determinations, and adapting their strategies to align with the proposed changes to enhance compliance and financial performance.

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Healthcare organizations should actively engage with these proposed changes and consider how they can adapt their RCM strategies accordingly. Keeping abreast of regulatory updates will not only enhance compliance but also improve financial performance in an increasingly complex healthcare environment.

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