April 7, 2023: Advocacy Update spotlight on prior authorization in Medicare Advantage

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CMS final rule moves to right-size prior authorization in Medicare Advantage
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CMS final rule moves to right-size prior authorization in Medicare Advantage

On April 5, the Centers for Medicare & Medicaid Services (CMS) released a final rule that revises Medicare Advantage and the Medicare prescription drug benefit. As the AMA continues to analyze the details of the rule, an initial read suggests that CMS has taken important steps toward right-sizing the prior authorization process imposed by Medicare Advantage plans on medical services and procedures. In February, the AMA and nearly 120 physician organizations sent a letter (PDF) to CMS Administrator Brooks-LaSure in strong support of the proposed prior authorization changes, and it seems that many of the provisions have been finalized.

The AMA applauds Administrator Brooks-LaSure for leading the effort to include provisions in this final rule that will ensure greater continuity of care, improve the clinical validity of coverage criteria, increase transparency of health plans’ prior authorization processes, and reduce care disruptions due to prior authorization requirements. The AMA has long advocated for such meaningful prior authorization reforms and Medicare Advantage enrollees will benefit from these important new protections. The AMA looks forward to working with CMS to bring a similar level of reform to Medicare’s drug benefit program.

The AMA will continue to review the rule and provide additional details on all of the reforms. These changes will take effect on Jan. 1, 2024. CMS has indicated that other proposed reforms such as gold carding and implementation of the real time prescription benefit standard will be addressed in a later rule.