Advocacy & Practice Updates — Advocacy & Practice

ASRS Advocacy Prompts CMS to Finalize Modifications to Prior Authorization in Medicare Advantage

This afternoon, CMS released a final rule for the 2024 Medicare Advantage (MA) and Part D Plan year. The final rule includes significant reforms to prior authorization regulations that were strongly supported by ASRS in our comments on the proposed rule. The final rule seeks to clarify plans’ ability to develop coverage criteria for medically necessary care and improve access for beneficiaries.
Specifically, the final rule:
  • Codifies regulations that require MA plans to cover the same items and services as original Medicare. Additionally, MA plans may not impose more restrictive coverage criteria than exists in Medicare’s national or local coverage determinations. 
  • Mandates that if there is no existing Medicare coverage determination, plans must develop coverage criteria using evidence from widely-used treatment guidelines or clinical literature that is made publicly available. 
  • Requires plans to provide a minimum 90-day transition period to cover previously authorized care when an enrollee currently undergoing treatment switches to a new MA plan. 
  • Requires plans to develop utilization management committees that review all policies annually. 
  • Clarifies a provision of the proposed rule to confirm that approval of a prior authorization request for a course of treatment must be valid for as long as medically reasonable and necessary.  
While this final rule does not make additional reforms that ASRS suggested in our comment letter on the proposed rule, such as reinstating the ban on step therapy, it is a significant policy achievement. ASRS and the medical community have been calling on CMS to provide oversight of MA plans use of prior authorization for many years, and this is the first action the agency has taken. We will continue to work with our coalition partners to expand on these important reforms. 

CMS released a fact sheet and press release along with the final rule. ASRS will continue to review the final rule and will provide additional analysis.

If you have questions please contact Allison Madson, vice president of health policy, at allison.madson@asrs.org.
(Published 4.5.23)