New CMS Prior Authorization Rule Reflects Academy Advocacy

The rule streamlines prior authorization requirements (in part by introducing continuity of care requirements) and bolsters access to behavioral health services in Medicare Advantage — reflecting the AAFP’s response to the proposed rule in February. As the Academy urged, the final rule will

• improve MA coverage criteria, increase transparency of prior authorization and medical necessity determinations, and prevent inappropriate coverage denials by MA organizations;
• strengthen MA network adequacy requirements and standards related to behavioral health;
• codify appointment wait-time standards for primary care and behavioral health services in MA;
• require that prior authorization be used only to confirm the presence of diagnoses or other medical criteria “and/or ensure that an item or service is medically necessary” — not to delay or dissuade care;
• set a minimum 90-day transition period for enrollees undergoing treatment while changing MA plans, during which the new MA plan may not require prior authorization for the active course of treatment; and
• require that approval of a prior authorization remain valid as long as medically reasonable and necessary, according to the treating clinician.

Reflecting longtime AAFP advocacy, the rule also requires MA organizations to establish a utilization management committee “to review policies annually and ensure consistency with traditional Medicare’s national and local coverage decisions and guidelines.

The rule also newly mandates that MA plans base their coverage policies on Medicare national and local coverage determinations, as well as peer-reviewed, publicly available data, another important return on the AAFP’s advocacy. The Academy applauded that element of the proposed rule as an important health-equity guardrail that would help to ensure that MA organizations not deny coverage or service “based on internal, proprietary or external clinical criteria not found in traditional Medicare coverage policies.”

Complementing these advances, the AAFP’s longstanding advocacy with the nation’s largest private payers yielded encouraging results earlier this month when UnitedHealthcare announced plans for a number of prior authorization reforms across its commercial, Medicare Advantage and Medicaid plans beginning later this year.

A burdensome prior authorization process hurts many of the more than 28 million Medicare beneficiaries who were enrolled in a Medicare Advantage plan in 2022. An April 2022 HHS report found that, among prior authorization requests that Medicare Advantage plans denied in 2019, 13% actually had met Medicare coverage rules.