CMS Releases FAQs on Medicare Advantage Plan Use of Artificial Intelligence

March 1, 2024 – On February 6th, the Centers for Medicare & Medicaid Services (CMS) issued a frequently asked questions (FAQs) document addressing Medicare Advantage (MA) plan development of coverage and prior authorization policy, including use of artificial intelligence (AI) and algorithms.

In the FAQ document, CMS states:

An algorithm or software tool can be used to assist MA plans in making coverage determinations, but it is the responsibility of the MA organization to ensure that the algorithm or artificial intelligence complies with all applicable rules for how coverage determinations by MA organizations are made.

However, the agency makes clear that even with appropriate use of AI or algorithms, MA plans must meet the already-established requirements for public transparency of coverage criteria policies. In the document, CMS states that MA plans should “refer to the coverage criteria and summary of evidence presented by Medicare Administrative Contractors (MACs) as a guide and best practice for how to present this information publicly.”

The FAQ document was issued as a follow-up to the CMS Interoperability and Prior Authorization final rule, which created additional new responsibilities for MA plans.  More information is available in the full CMS FAQ document.  The CMS Office of Burden Reduction & Health Informatics will host an information session on the final rule on March 26th from 1:00 pm to 2:00 pm (eastern). To register for the webinar, follow this link.