CMS Finalizes Prior Authorization Reform for Medicare Advantage Plans


On April 5, 2023, the U.S. Department of Health and Human Services (HHS), and the Centers for Medicare & Medicaid Services (CMS), finalized its 2024 Medicare Advantage (MA) and Part D Rule.

The final rule streamlines prior authorization requirements by requiring plans:
(1) Uphold a prior authorization approval for as long as the treatment is medically reasonable and necessary;
(2) Establish a Utilization Management Committee to annually review coverage policies;
(3 Develop a 90-day coordinated care plans when an enrollee is transitioning from one MA plan to a new MA plan; and
(4) Use health care professionals with relevant expertise when reviewing coverage requests and denials.

The final rule also requires appeals for Medicare-covered items or services be reviewed by an internal and external appeals board, rather than through Medicare coverage policies; and prohibits a new MA plan from requiring a new prior authorization for an active course of treatment.

Other health equity provisions include establishing a new health equity index in the Star Ratings program to reward Medicare Advantage and Medicare Part D plans that provide excellent care for underserved populations; requiring plans to provide culturally competent care to an expanded list of populations; and implementing provisions of the Inflation Reduction Act and the Consolidated Appropriations Act of 2021 concerning prescription drug affordability and coverage for eligible low-income individuals.

Read the CMS press release here.

Last Updated on April 14, 2023 by Aimed Alliance


Comments are closed.