Policy and Technical Changes to the Medicare Advantage Program

Request for Public Comment

Medicare Advantage Medicare Program; Contract Year 2027 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, and Medicare Cost Plan Program

CMS-4212-P

Rubrum Advising appreciates the opportunity to comment on the Centers for Medicare and Medicaid Services (CMS) 2027 proposed policy and technical changes to the Medicare Advantage (MA) Program and accompanying Request for Information (RFI). Rubrum Advising (“Rubrum”), founded by Lee Fleisher, MD, former CMS Chief Medical Officer and Director of the Center for Clinical Standards and Quality, advises clients on matters pertaining to the adoption, diffusion, and reimbursement of innovative solutions and products to improve patient outcomes and reduce total costs of healthcare within the context of regulation, safety, quality, and clinical standards.

Our comment supports CMS’s efforts to modernize MA by advancing a next-generation risk adjustment model, aligning Star Ratings and quality measures with clinically meaningful outcomes, and strengthening transparency and beneficiary protections in prior authorization and utilization management. These changes will promote equitable access to medically necessary, evidence-based care while improving oversight and accountability across MA plans.

I.  Risk Adjustment and Quality Bonus Payment Changes

Rubrum agrees that aspects of the current MA risk-adjustment methodology may disadvantage smaller, newer, and less-resourced plans, including those serving beneficiaries in rural communities. Rubrum strongly supports CMS’s exploration of a “next-generation” risk adjustment model that more accurately reflects enrollee needs and the intensity of medically necessary care while mitigating incentives to over-code. In designing a next-generation model, CMS should consider implementing the following enhancements:

• Alignment Between Coding and Clinical Care: Require plans to report process and outcome measures that align with coded comorbidities and conditions. This requirement should include: (1) in-home assessments to validate diagnoses in high-risk populations; (2) verification that diagnoses are documented in patients’ medical records; and (3) documentation that identified conditions are addressed through appropriate clinical encounters and interventions or at a minimum acknowledged in the primary clinician notes as part of care planning. These measures will ensure that coded conditions reflect genuine patient needs rather than coding artifacts.
• Analysis of Denials and Non-Coverage Patterns: CMS should utilize anonymized datasets that reflect the MA beneficiary experience with medical technologies, including device-dependent service lines often subject to prior authorization or non-coverage. This data should be analyzed to identify service lines and populations most affected by MA denials and non-coverage policies and quantify downstream impacts on both plan revenue and clinical outcomes. This analysis should investigate underlying incentives for certain denial and non-coverage patterns, identifying policy drivers or gaps that contribute to adverse outcomes, particularly for high-need and underserved populations.
• Integration with Quality Measurement: CMS should establish stronger alignment between risk adjustment methodologies, quality bonus payments, and Star Ratings so that high rates of inappropriate denials (as documented by overturned denials on subsequent review or ALJ decisions), delays, or barriers to care result in meaningful consequences, including potential Star Rating reductions. Specifically, measures such as the percent of overturned denials and beneficiary ease of access to specialty care should be incorporated into MA ratings.
• Standards for “Experimental or Investigational” Designations: CMS should enforce clear standards that plans must use to justify designation of certain items and services as “experimental or investigational.” When denials based on this justification occur for patients with relevant coded conditions, these cases should be flagged and warrant automatic appeal. Star Ratings should adjust downward when “experimental or investigational” policies are non-compliant with established standards, including technologies covered under Coverage with Evidence Development decisions.

II.  Star Ratings and Enrollment Experience

Rubrum generally supports CMS’s proposal to streamline the MA Star Rating system by eliminating redundant measures. This streamlining will allow plans to concentrate resources on areas that directly impact patient care and clinical outcomes. However, to realize the benefits of these changes, Rubrum recommends that HEDIS measures evolve concurrently with this streamlining.

Specifically, CMS should reduce reliance on administrative process measures and increase the relative weight of clinical HEDIS measures. This rebalancing should include enhanced emphasis on serious-illness-related metrics such as advance care planning, which reflect meaningful improvements in beneficiary outcomes and align with the clinical priorities of the modernized program.

III.  Transparency, Oversight, and Beneficiary Protection

Rubrum recommends that CMS strengthen guardrails around prior authorization and utilization management to ensure that MA plans cannot use these administrative tools to deny or delay coverage that would otherwise be available to beneficiaries under Traditional Medicare. Specific measures should include:

• Coverage Criteria Transparency and Standards: When internal coverage criteria are used, they should be publicly posted in an accessible format and based on accepted medical standards or current evidence from widely used treatment guidelines and clinical literature. Where additional criteria are needed to interpret general Medicare provisions, plans must demonstrate that the additional criteria provide clinical benefits highly likely to outweigh any clinical harms and must systematically explain these benefits to beneficiaries and CMS.
• Enhanced Denial Documentation: Denial letters should clearly state the Medicare basis for denial or, where permitted, the specific internal coverage criteria applied and should identify where supporting evidence and criteria can be found. Letters should identify any missing information and provide clear, expedited pathways to approval and appeal.
• Prohibition of Criteria Without Medical Justification and Utilization Reduction: CMS should prohibit the use of internal coverage criteria or additional prerequisites where the criterion lacks clinical benefit and exists solely to reduce utilization. Similarly, CMS should prohibit the automatic denial of basic benefits without individual medical necessity determinations.
• Documentation and Reauthorization Guardrails: CMS should develop a strategy to prohibit denials based on missing documentation when the plan already has sufficient information to make a coverage determination. This policy should be reflected in analyses of overturned denials and could be used to reduce a plan’s Star Ratings. Generally, CMS should tighten guardrails around documentation requests and requirements. Additionally, CMS should discourage episodic reauthorization that interrupts ongoing, stable treatment plans without meaningful clinical changes in the patient’s condition.
• Continuity of Care and Compliance Monitoring: CMS should enforce recently finalized continuity protections for new enrollees mid-course of treatment, including the 90-day minimum transition period during which new plans cannot require prior authorization for active courses of treatment. Additionally, plans should be required to track inaccurate denials and implement corrective actions, including systematic fixes to claims processing systems and manual review procedures. CMS should continue to encourage MAOs to streamline prior authorization requirements for contracted providers (gold-carding program) that have demonstrated consistent compliance with plan policies.
• Enhanced Audit and Oversight: We recommend increasing audit frequency and scope, with particular emphasis on: (1) prior authorization review decisions; (2) annual risk adjustment data validation audits to support adherence and parity with traditional Medicare; and (3) focused review of “experimental or investigational” designations and their clinical justifications.

IV.  Conclusion

Rubrum commends CMS’s commitment to modernizing the MA program through these proposed policy and technical changes. Implementation of the recommendations outlined above will help ensure that MA beneficiaries, particularly those in rural and underserved communities, receive equitable access to clinically appropriate care. We look forward to working with CMS as these important reforms are implemented.

Sincerely,

Lee A. Fleisher, M.D., M.L.
Principal and Founder, Rubrum Advising
Former CMS Chief Medical Officer and Director of the Center for Clinical Standards and Quality
Centers for Medicare and Medicaid Services (2020–2023)