CMS Releases Proposed Rule on New Prior Authorization and Coverage Guidelines For Medicare Advantage

The Centers for Medicare and Medicaid Services (CMS) has released the Medicare Program: Contract Year 2024 Policy and Technical Changes to the Medicare Advantage Program proposed rule, which includes provisions addressing the utilization of prior authorization by Medicare Advantage (MA) organizations.

The proposed rule outlines several prior authorization requirements, including creating a 90-day transition period for enrollees switching to a new MA plan and mandating that plans must comply with national coverage determinations, local coverage determinations, and general coverage and benefit conditions included in traditional Medicare statutes and regulations. CMS also proposes a requirement where MA plans must create a Utilization Management (UM) Committee to annually review all UM and prior authorization policies to ensure consistency with existing Medicare policies and determinations.

These proposals come as a result of last summer's MA prior authorization report from the Department of Health and Human Services Office of the Inspector General highlighting inconsistent prior authorization coverage guidelines and delays in patient care.

ACC Advocacy staff are currently reviewing the proposed rule for opportunities to provide feedback and comments to CMS. For more information, access the CMS fact sheet.

Keywords: ACC Advocacy, Medicare Part C, Centers for Medicare and Medicaid Services, U.S., Prior Authorization, Medicaid, Feedback, Policy

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