Prior Authorization Reform: CMS rule aimed at improving Medicare Advantage draws praise

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Editor’s Note: While there is a patient-centric intent to many prior authorization (PA) practices, they often create a significant operational burden for healthcare providers and disrupt the patient experience. Today, most branded medications witness low HCP PA submission rates which in turn result in high rates of prescription abandonment and manufacturer patient assistance overutilization. Both have negative consequences for pharmaceutical brands that are most commonly felt in the form of reduced brand loyalty and gross to net (GTN). While the current CMS proposal that calls for Medicare Advantage (MA) plans to streamline the prior authorization process is a positive step forward for stakeholders, brands should not bet on the new regulations being a “silver-bullet” in easing the prior authorization burden. The PHIL Platform has thoughtfully designed a software driven prior authorization process that supports patients and HCPs in completing the steps required to submit PAs resulting in an 85% PA submission rate across our programs - far exceeding industry benchmarks. To learn more about how Phil can help your prior authorization strategy visit:

A new CMS rule designed to strengthen Medicare Advantage is generating positive feedback for its proposals to streamline the prior authorization process, expand access to behavioral health care, make prescription drugs more affordable and stop misleading advertising.

Among other changes, the rule would revise prior authorization requirements to reduce disruption for enrollees, so that an approval would remain valid for a full course of treatment. MA plans would be required to review utilization management policies annually, with coverage determinations evaluated by professionals with relevant expertise.

The proposed rule released last week takes "important steps to hold Medicare Advantage plans accountable for providing quality coverage and care to enrollees," CMS Administrator Chiquita Brooks-LaSure said in a statement.

The rule seeks to clarify regulations governing how MA plans develop coverage criteria to ensure enrollees receive the same access to medically necessary care that they would get through traditional Medicare. In a statement, the American Hospital Association commended the CMS for increasing oversight of MA plans to protect enrollees’ access to medically necessary services. The hospital lobby had previously raised concerns about some MA practices it viewed as having the potential to harm patients through unnecessary care delays or outright denial of covered services.

Provisions in the CMS proposal would create more consistency between MA and traditional Medicare and curb overly restrictive policies that can impede access to care and add cost to the healthcare system, the AHA said.

Group purchasing organization Premier also weighed in on the proposal, saying the CMS' effort to make sure health plans are not inappropriately delaying or denying coverage for necessary services will empower providers’ clinical decision-making and protect beneficiaries.

"Coupled with CMS’ recent proposal to require electronic prior authorization, these protections will go far in modernizing what is now a burdensome, highly manual and costly process that can lead to wasted time, resources and harm to patients," Soumi Saha, Premier's senior vice president for government affairs, said in a statement.

Premier also endorsed parts of the rule aimed at advancing health equity, including a health equity index in the star ratings program to reward plans that are improving care for underserved populations.

Both Premier and the AHA applauded the CMS’ focus on closing care access gaps in behavioral health services. The rule aims to strengthen behavioral health networks by adding clinical psychologists, licensed clinical social workers and prescribers of medication for opioid use disorder to the list of evaluated specialties.

It would require most MA plans to include behavioral health services in care coordination programs and would set new minimum wait time standards for behavioral health and primary care. Plans would be required to notify patients when providers are dropped from their networks.

The rule also aims to crack down on misleading marketing and improve access to accurate information for people looking to make coverage choices. The rule would prohibit ads that do not mention a specific plan name and that use words, imagery and logos in confusing ways. The CMS proposed guidance to protect people from pressure to enroll in plans and to strengthen the role of plans in monitoring agent and broker activity.

Senate Finance Committee Chairman Ron Wyden, D-Ore., a proponent of better protections against aggressive sales techniques and misleading advertising, expressed support for the plan, noting deceptive marketing practices have increased in recent years.

The CMS rule also implements a provision of the Inflation Reduction Act to help Medicare beneficiaries with modest incomes afford their prescriptions. The proposal would expand eligibility under the low-income subsidy program to allow people with incomes up to 150% of the federal poverty level who meet statutory resource requirements to qualify for the full subsidy starting in 2024.

Comments on the proposed rule are due Feb. 13.

This article was written by Susan Kelly from Healthcare Dive and was legally licensed through the Industry Dive Content Marketplace. Please direct all licensing questions to

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