On April 5, CMS released a final rule that addresses changes to the prior authorization process under Medicare Advantage (MA), as well as a number of other program changes.
Prior Authorization has been one of our main advocacy issues for years (and more recently in our coalition comments and ACAAI comments) and it appears that many of our recommendations have been included in the new rule. While a further and more detailed read of the rule is required, regarding prior authorization reforms, it appears that CMS initiated reforms to:
- Ensure greater continuity of care.
- Improve the clinical validity of coverage criteria.
- Increase transparency of plans’ prior authorization processes.
- Reduce care disruptions due to prior authorization requirements.
The new rule also provides important protections concerning utilization management policies and coverage criteria, ensuring that Medicare Advantage enrollees receive the same access to medically necessary care that they would receive in Traditional Medicare. It:
- Streamlines prior authorization requirements.
- Reduces disruption for enrollees by requiring that a granted prior authorization approval remains valid for as long as medically necessary to avoid disruptions in care.
- Requires Medicare Advantage plans to annually review utilization management policies.
- Requires denials of coverage based on medical necessity be reviewed by health care professionals with relevant expertise before a denial can be issued.
These changes become effective on January 1, 2024. CMS plans to address other proposed reforms – such as gold carding and implementation of the real time prescription benefit standard – in a later rule.
We appreciate CMS taking these initial steps for meaningful prior authorization reforms but our work is not done. We will continue to advocate to reduce administrative burdens and reduce the patient harm often associated with MA prior authorization requirements. We’ll keep you advised as these reforms unfold.
The Advocacy Council – ADVOCATING FOR ALLERGISTS AND THEIR PATIENTS.