CMS Streamlines Prior Authorization for MA in New Rule

Last week, the Centers for Medicare and Medicaid Services released a final rule taking aim at prior authorization and its use in Medicare Advantage. The rule also makes changes to the star ratings program and marketing reforms.

The rule stipulates that once a health plan grants prior authorization for a service, the approval will remain valid “for as long as medically necessary,” Radiology Business reports. It will also require Medicare Advantage plans to review their use of prior authorizations and review denials based on medical necessity with healthcare professionals with relevant backgrounds.

From the CMS fact sheet:

CMS has received numerous inquiries regarding the use of prior authorization by Medicare Advantage plans and the effect on beneficiary access to care. In the rule, CMS finalizes impactful changes to address these concerns and to advance timely access to medically necessary care for enrollees.

STAT notes that insurers will be asked to create “utilization management committees” for their reviews, in order to ensure that coverage is “no more restrictive than traditional Medicare coverage criteria.” Insurers will also be able to deny care if Medicare rules are “not fully established,” and “based on current evidence in widely used treatment guidelines or clinical literature.”

CMS will also establish a health equity index within the star ratings program that aims to incentivize plans to address needs in underserved populations. Healthcare Innovation notes that the ratings changes will require plans to take extra steps beyond demographic inclusion:

Plans will also be required to provide culturally competent care to an expanded list of populations and to improve equitable access to care for those with limited English proficiency, through newly expanded requirements for providing materials in alternate formats and languages. The final rule balances patient experience/complaints measures, access measures, and health outcomes measures in the star ratings program to more effectively focus on patient-centric care and on improving clinical outcomes.

Fierce Healthcare notes that coordinated care plans must offer a 90-day transition period if an enrollee under treatment switches to a new MA plan and the new plan is not allowed to require prior authorization for the course of treatment. CMS also stipulated that MA plans must follow national or local coverage determinations.