Hospitals: UHC's 2024 MA coverage policy 'blatantly violates' new CMS coverage requirements

Hospitals are petitioning the Biden administration to crack down on Medicare Advantage (MA) plans they say are flouting coverage requirements recently codified by the Centers for Medicare & Medicaid Services (CMS).

In letters sent Monday to CMS officials, the American Hospital Association (AHA) and the Federation of American Hospitals (FAH) pointed to a coverage policy for inpatient hospital care distributed by UnitedHealthcare and set to go into effect Jan. 1.

That policy “blatantly violates” coverage criteria revisions included in the calendar year 2024 MA final rule that prohibit MA plans from limiting or denying coverage for hospital services that would be covered under traditional Medicare, FAH President and CEO Chip Kahn said in a statement accompanying his organization’s letter to CMS.  

“Among other concerns, UHC continues to use proprietary software that unlawfully narrows MA beneficiaries’ inpatient hospital benefits, creating patient care risks as well as higher cost-share burdens,” Kahn said. “Medicare beneficiaries should not be shortchanged by UnitedHealthcare or any MA plan. We have flagged UnitedHealthcare’s unlawful policies for CMS and pledge to work with the Agency to ensure Medicare’s coverage policies for all of America’s seniors.”

CMS implemented the updated utilization management requirements in the wake of an Office of Inspector General report that found MA plans “sometimes delayed or denied Medicare Advantage beneficiaries' access to services, even though the requests met Medicare coverage rules,” including prior denied authorization requests for services that “likely would have been approved” under original Medicare.

UHC, the largest MA provider in the country, outlined its use of the proprietary, nonpublic InterQual criteria and other UHC commercial medical policies in guidance approved Oct. 30 (PDF) and recently distributed to network providers, the groups wrote.  

In AHA’s letter to CMS, the hospital lobbying group said it learned from members “that at least one other large, national [MA operator] has reported they will continue to use Milliman Clinical Guidelines (MCG) criteria to evaluate inpatient admissions,” AHA wrote in its letter. “And yet another plan [later specified as Aetna] has issued a policy that adopts a more stringent standard than CMS for evaluating a physician’s judgement at the time of admission on whether the care was expected to extend over two midnights.”

In an email statement, a spokesperson for UHC said the hospital groups are “advocating a position that is inconsistent with language in the CMS Final Rule for 2024. Our Medicare Advantage Hospital, Emergency, and Ambulance Services Coverage Policy complies with CMS' Final Rule.”

CMS’ rule does permit MA plans to create and use internal coverage criteria when making medical necessity decisions in circumstances outlined by the agency where coverage criteria are not fully established.

“CMS believes that permitting the use of publicly accessible internal coverage criteria in limited circumstances is necessary to promote transparent, and evidence-based clinical decisions by MA plans that are consistent with traditional Medicare," CMS wrote in a fact sheet at the time.

AHA wrote in its letter that CMS’ flexibility for MA plans to create internal coverage criteria as outlined in UHC’s guidance “is not applicable for medical necessity reviews of inpatient admissions and level of care decision should only be used in certain limited circumstance.”

It and FAH called on CMS to further clarify this point, specify that coverage criteria for inpatient admissions “are fully established under traditional Medicare” and that the agency “undertake appropriate enforcement actions against UHC so that UHC’s 8.9 million members will receive their full inpatient hospital benefits based on established and clear Traditional Medicare coverage criteria.”