Advocacy & Practice Updates — Advocacy & Practice

CMS Proposes ASRS-Supported Reforms to MA Prior Authorization

Today, CMS released a proposed rule to establish policies for the 2024 Medicare Advantage (MA) and Part D program year. Following several years of advocacy from ASRS and others in the medical community, CMS is proposing changes to address prior authorization in the MA program. ASRS has previously recommended CMS implement some of these proposals.
To ensure beneficiaries receive medically-necessary care, CMS proposes to:
  • Allow MA plans to create coverage criteria based on current evidence in widely-used treatment guidelines or clinical literature when there is no national or local coverage decision, but require plans make that information publicly available to CMS, enrollees and providers.  
  • Require that physicians or other healthcare professionals involved in developing MA plan policies to deny coverage have expertise in the field of medicine that is appropriate for the service.  
  • Reduce disruptions in care by requiring that when an enrollee is granted prior authorization approval it will remain valid for the full course of treatment and provide a 90-day authorization grace period for enrollees changing plans.  
  • Require MA plans to establish a Utilization Management Committee to review policies annually and ensure consistency with traditional Medicare’s national and local coverage decisions and guidelines.
In addition, CMS proposes new restrictions on MA plan marketing materials to address beneficiary complaints about deceptive marketing practices.
ASRS will continue to review the proposed rule and provide additional details in future publications. The rule includes a 60-day comment period. ASRS will submit comments. Additional details on the rule are available on the CMS website.
If you have questions, or need assistance, please contact Allison Madson, vice president of health policy, at allison.madson@asrs.org.
(Published 12.14.22)