In a win for APTA and other organizations fighting to reduce administrative burden, the U.S. Centers for Medicare & Medicaid Services has put up additional guardrails on the use of prior authorization in Medicare Advantage plans. Among the provisions of the 2024 MA final rule: limits on the application of prior authorization, assurances that a prior authorization approval remains valid as long as medically necessary, and accommodations for patients in transition from one MA plan to another.

Prior Authorization Versus Preserving Continuity of Care

Taken as a whole, the prior authorization-related changes in the final rule are aimed at ensuring MA plans don't apply requirements that disrupt care. According to a CMS fact sheet, the intent is to ensure that MA enrollees receive the same services and items as beneficiaries in the Medicare fee-for-service program. Among the changes:

Prior Authorization Approvals to Remain in Effect for as Long as Necessary
In a significant shift that will place greater weight on clinician judgment, an approval of a prior authorization request for a course of treatment now must be valid for as long as medically necessary to avoid disruptions in care in accordance with applicable coverage criteria, the patient's medical history, and the treating provider's recommendation. These changes were made to the existing minimum continuity and coordination-of-care requirements.

Limits on Prior Authorization Use
The final rule limits MA plans’ ability to employ prior authorization and utilization management policies for reasons beyond confirming the presence of diagnoses or other medical criteria, or to ensure that a service or item is medically necessary. While these requirements aren't new, CMS is reminding MA plans that they need to follow them.

Protections for Enrollees in MA Plan Transitions
MA enrollees switching to a new plan while undergoing a current course of treatment now will be granted a minimum 90-day transition period during which the new MA plan may not require prior authorization for the "active course of treatment," defined by CMS as "a course of treatment in which a patient is actively seeing a provider and following the prescribed or ordered course of treatment as outlined by the provider for a particular medical condition."

The MA Rule Beyond Prior Authorization

The final rule includes changes other than prior authorization, most related to the aim of preserving care continuity. Among them:

Reviews Required Prior to a Denial
CMS will apply the same review standards used when an MA plan is intending to deny a prior authorization request as the process currently in place when a denial is appealed: specifically, a review by a physician with appropriate expertise in the field of medicine for the services at issue.

Consistency in Coverage Criteria
The final rule also clarifies that MA plans cannot create coverage criteria that veers from or ignores traditional Medicare coverage criteria, including compliance with national and local coverage determinations. MA plans will be permitted to create internal coverage criteria in areas for which Medicare hasn't, but that criteria must be based on widely used, widely available treatment guidelines or clinical literature.

Creation of UM Committees
Although CMS is clear that audits will be an important part of enforcement behind these finalized policies, it also requires MA plans to establish utilization management committees to review policies and ensure consistency with Medicare national and local coverage decisions by January 1, 2024. The agency views the UM committee as a critical mechanism to ensure MA plans are held accountable for ensuring UM policies are compliant.

(A Lot) More Happening Around Prior Authorization

The prior authorization changes to MA are part of what appears to be an initial CMS reconsideration of the concept across several programs it oversees. The most sweeping final prior authorization rule has yet to be released, but its proposed version introduced welcome reforms in state Medicaid and Children's Health Insurance Plan fee-for-service programs, Medicaid managed care plans, CHIP managed care entities, and Qualified Health Plan issuers in the federal ACA insurance exchanges. That final rule is expected in the coming weeks.

Movement on prior authorization is also happening at the commercial payer level. Beginning in January, Aetna lifted precertification requirements for physical medical services in Delaware, New Jersey, New York, Pennsylvania, and West Virginia, while UnitedHealthcare recently announced that it will eliminate nearly 20% of current prior authorization requirement beginning in the third quarter of 2023 for commercial, MA, and Medicaid businesses.

Meanwhile, APTA and its components continue to advocate for reduced administrative burden and provide tools for PTs to respond to denials made in error, among other issues. Earlier this year, the association led a highly successful letter-writing initiative around large-scale changes proposed by CMS, and updated an infographic that outlines how administrative burden, including prior authorization, impacts PT services. In addition to those advocacy efforts, APTA continues to collaborate with APTA Private Practice to expand the resources available to members through the State Payer Advocacy Resource Center, which offers tools to help with payment advocacy around prior authorization and more.