Medicare Advantage Plans’ Prior Auth Rules Would Be Made Public Under CMS Proposal

Medicare Advantage plans’ prior authorization rules and coverage criteria would become publicly available under a proposed rule issued Tuesday by the Centers for Medicare & Medicaid Services (CMS).

The Biden Harris administration has “worked over the last 3 years to reform the way that Medicare Advantage plans can use prior authorization to ensure that patients can access the care they need,” Meena Seshamani, MD, PhD, director of the Center for Medicare, said on a call with reporters. “Today, we are taking an additional step further to address the inappropriate use of prior authorization.”

“Data reported to CMS by MA [Medicare Advantage] plans indicates that, on average, MA plans overturn 80% of their decisions to deny claims when those claims are appealed to the plan,” she continued. “But these data also show that less than 4% of denied claims are appealed in the first place, meaning that many more denials could potentially be overturned by the plan if they were appealed. And what this means is that more patients could likely have access to care if inappropriate prior authorization did not block it.”

The rule would make Medicare Advantage plans’ prior authorization rules more transparent, Seshamani told MedPage Today on the call. Plans will need to “clarify what the coverage criteria are and make sure that they are made available to the public,” she said. “In addition, we are proposing to require that plans provide information on appeals rights to their enrollees … So what we are trying to do is both tighten up MA plans’ clinically appropriate coverage criteria, and make sure that people know what those criteria are, and that they know that they can appeal if they have a denial.”

The proposed rule also addresses an issue with provider directories in Medicare Advantage. “We know that seniors are presented with many options when choosing Medicare coverage that is best for them, and the primary way that they evaluate coverage is using Medicare Plan Finder,” said Seshamani. “Based on research and the public input, CMS is proposing … that MA organizations make their entire provider directory available to CMS for the purpose of incorporating it into Medicare Plan Finder. This would enable people with Medicare and their caregivers to search for providers and more easily compare their availability across different MA plans. Ensuring that people with Medicare are able to evaluate their coverage and their unique circumstances is critical and helps to empower them to make the right individual choices.”

Sen. Ron Wyden (D-Ore.), chair of the Senate Finance Committee, praised the proposed rule. “Today’s announcement marks an important step to update and strengthen the Medicare guarantee for Americans,” Wyden said in a statement. “In Medicare Advantage, there are a number of promising actions to limit the overuse of prior authorization, crack down on the prevalence of ‘ghost networks’ that leave seniors unable to find a doctor, and prevent unscrupulous brokers from taking advantage of seniors by enrolling them in a plan that may not work for them.”

The comment deadline for the proposed rule is 5 p.m. on Jan. 27, 2025. It will be up to the incoming Trump administration to decide whether to continue work on the proposed rule.

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