Medicare Advantage and Prior Authorization Improvements

On April 5, 2023, the Centers for Medicare & Medicaid Services (CMS) finalized an IPSIS-supported rule that will provide necessary increased oversight of Medicare Advantage (MA) plans — improving their conformity with traditional Medicare and simplifying the prior authorization (PA) process. The rule's provisions apply to coverage beginning January 1, 2024.

• MA plans will now be required to provide coverage for the same medically necessary services as traditional Medicare plans. Coverage policies must also not be more restrictive than national and local coverage determinations that apply to the fee-for-service program.
  
• The plans must now establish utilization management committees to review their coverage policies annually.
  
• In cases where national and local coverage determinations do not specify medical coverage, the utilization management committees may develop plan-specific coverage criteria. The committees are required to publish the rationale supporting these policies and base them on publicly accessible clinical literature and widely used treatment guidelines.
  
• Plans may only use PA to confirm medical necessity and not to delay or discourage care.
  
• Plans must maintain the validity of PA throughout the patient's treatment if it is medically reasonable and necessary.
  
• Plans must offer a minimum 90-day transition period to new enrollees undergoing treatment with PA from a previous MA carrier.
  

IPSIS previously voiced support for CMS’s recognition of the challenges associated with PA programs. Additional information on the rule can be found using the following CMS resources:

CMS Fact Sheet
CMS Press Releases

You can also help sustain this vital advocacy with your donations. The International Pain and Spine Intervention Society (IPSIS) is a tax-exempt organization under US section 501(c)(3) of the Internal Revenue Code. As such, contributions are deductible to the extent allowed by law.