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CMS Proposed Rule Changes for MA Patients

CMS proposed rule impacts how hospitals determine LOS for MA patients


The Centers for Medicare and Medicaid Services (CMS) recently proposed rule changes (CMS-4201) that could have a significant impact on how hospital utilization management determines level of care for Medicare Advantage patients.

The proposed rule1 reflects the agency’s focus on increasing transparency, improving health equity, reducing the cost of care, and improving access to behavioral health services.2

AppriseMD supports the changes proposed in the new rule that would require MA plans to abide by the Two-Midnight Rule and prohibit the use of commercial criteria in admission status determination. These changes are good for hospitals in terms of a lighter burden on utilization review teams with anticipated less admission denials. For utilization management teams and patients, “The rule proposes to increase the transparency of MA plans’ utilization management and prior authorization policies, with the goal of ensuring that MA enrollees receive the same access to medically necessary care they would receive in Traditional Medicare.”2

CMS proposed rule highlights3:

  1. Requirement of MA plans to abide by the Two-Midnight Rule.
  2. Prohibition of the use of commercial criteria in admission status determination.
  3. Adoption of Traditional Medicare SNF/IRF criteria for MA patients.
  4. Creation of an MA Utilization Management Committee.

The American College of Physician Advisors is encouraging comment on the proposed rule. Hospital administrators and physician advisors can comment here; the comment period ends Feb. 13, 2023.

You can also download a template to submit comments. The form can be uploaded on the link above in the “Submit a formal comment” area.




  1. Medicare Program; Contract Year 2024 Policy and Technical Changes to the Medicare Advantage …” Federal Register, The Daily Journal of the United States Government. Program. December 27, 2022.
  2. CMS introduces significant proposed changes to Medicare Advantage and Medicare Prescription Drug Benefit Programs for 2024,” Health Management Associates. December 22, 2022.
  3. The American College of Physician Advisors (ACPA) Juliet B. Ugarte Hopkins, MD, President, American College of Physician Advisors Communication. January 19, 2023.
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