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CMS Issues Final Rule Reforming Parts of Prior Authorization Requirements


On April 5, the Centers for Medicare & Medicaid Services (CMS) issued a final rule reforming parts of prior authorization requirements for Medicare Advantage (MA) and Part D beneficiaries.

The rule creates enforcement provisions for misleading marketing schemes, removes barriers to care created by complex coverage criteria, and expands access to behavioral health care. OSMA joined with the American Medical Association in supporting these needed reforms.

The final rule clarifies clinical criteria, requiring that MA plans comply with national coverage determinations, local coverage determinations, and general coverage and benefit conditions ensuring that access of MA beneficiaries is the same as traditional Medicare.

The rule requires coordinated care plan prior authorization policies only to be used to confirm that an item or service is medically necessary, and it requires plans to provide a 90 day transition period when enrollees are undergoing treatment and are switching MA plans—specifically that the new plan cannot require PA during that time for that active course of treatment. The rule requires MA plans to create committees to review and ensure that they are consistent with traditional national and local coverage decisions.

Additionally, the rule prohibits advertising that may confuse beneficiaries or represent Medicare logos misleading and confusing way that doesn’t properly represent the offerings of the plan.

Further, the rule attempts to bridge the educational and digital divide by requiring MA plans to improve services to a non-exhaustive list of populations in a culturally competent way. Some of the populations are people:

(1) with limited English proficiency or reading skills.

(2) of ethnic, cultural, racial, or religious minorities.

(3) with disabilities.

(4) who identify as lesbian, gay, bisexual, or other diverse sexual orientations.

(5) who identify as transgender, nonbinary, and other diverse gender identities, or people who were born intersex.

(6) who live in rural areas and other areas with high levels of deprivation.

(7) otherwise adversely affected by persistent poverty or inequality.

Finally, the rule aims to improve MA plan beneficiaries access to behavioral health by, among other things, requiring general access to service standards to include behavioral health, clarifying that emergency behavioral health services are not subject to PA, and requiring MA organization to create coordination care programs for behavioral health services to improve parity between behavioral and physical health services.

OSMA is encouraged by the improvements made by CMS in this finalized rule, and will continue to push for additional improvements in prior authorization.

Review the rule & related materials >

If you have questions, please email Sean McCullough.


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