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Groups Commend Prior Authorization Requirements in Medicare Advantage Final Rule

Analysis  |  By Jay Asser  
   April 11, 2023

The changes aim to provide consistent access to medically-necessary care while reducing delays for beneficiaries.

Prior authorization policies in CMS' Medicare Advantage (MA) final rule have garnered widespread support from medical and payer groups for streamlining the administrative process.

As part of the rule, prior authorization approvals are required to remain valid for as long as medically necessary, while denials of coverage based on medical necessity must be reviewed by healthcare professionals with relevant expertise before a denial can be issued. MA plans are also required to annually review utilization management policies.

Additionally, the rule requires that coordinated care plan prior authorization policies may only be used to confirm the presence of diagnoses or other medical criteria and/or ensure that an item or service is medically necessary, according to the fact sheet released by CMS. Coordinated care plans must also provide a minimum 90-day transition period when an enrollee underdoing treatment switches to a new MA plan, during which the new MA plan cannot require prior authorization for the active course of treatment.

Here’s how groups reacted to the prior authorization changes in the rule:

American Hospital Association (AHA)

"Hospitals and health systems have raised the alarm that beneficiaries enrolled in some Medicare Advantage plans are routinely experiencing inappropriate delays and denials for coverage of medically necessary care," said Ashley Thompson, AHA senior vice president of public policy analysis and development. "This rule will go a long way in protecting patients and ensuring timely access to care, as well as reducing inappropriate administrative burden on an already strained health care workforce."

American Medical Association (AMA)

"The AMA applauds CMS Administrator Brooks-LaSure for leading the effort to include provisions in this final rule that will ensure greater continuity of care, improve the clinical validity of coverage criteria, increase transparency of health plans' prior authorization processes, and reduce care disruptions due to prior authorization requirements," said Jack Resneck Jr., AMA president. "The AMA has long advocated for such meaningful prior authorization reforms and Medicare Advantage enrollees will benefit from the important new protections."

Medical Group Management Association (MGMA)

"MGMA supports today's action by CMS to finalize its proposals to reign in detrimental prior authorization practices, thereby strengthening the Medicare Advantage (MA) program," said Anders Gilberg, MGMA senior vice president of government affairs. "We are thankful that the agency heeded our call to finalize the continuity of care provision, limiting dangerous disruptions and delays to necessary patient care."

Better Medicare Alliance

"CMS' final policy rule for 2024 will support Medicare Advantage's efforts in bridging the health equity gap and providing high-quality care," said Mary Beth Donahue, president and CEO of Better Medicare Alliance. "Further, we support provisions to streamline the prior authorization process to ensure timely access to care as well as steps to ensure transparency and accountability within Medicare Advantage."

Jay Asser is the contributing editor for strategy at HealthLeaders. 


KEY TAKEAWAYS

The Medicare Advantage final rule requires prior authorization approvals to remain valid for as long as medically necessary and offers coordinated care plan protections for patients.

Groups such as the American Hospital Association and Medical Group Management Association have applauded the regulations.


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