CMS Finalizes Rules Reigning in the Use of Prior Authorization by Medicare Advantage Plans

April 19, 2023

Navigating coverage for patients with Medicare Advantage (MA) might get a bit easier due to new regulations issued by the Centers for Medicare & Medicaid Services (CMS) in April 2023, which ASHA supported [PDF] earlier this year.

Prior Authorization

Patients and clinicians have reported ongoing challenges navigating utilization management techniques, such as prior authorization, for MA patients that delays or prevents access to critical health care services. Under the new rules, utilization management techniques must align with Medicare national and local coverage determinations (NCDs and LCDs, respectively), among other standards. Examples of utilization management techniques often used to dictate coverage decisions include the use of proprietary coverage guidelines or artificial intelligence (AI) products.

Other Finalized Prior Authorization Policies

If there is not an applicable coverage policy in statute, regulation, or NCD or LCD associated with a particular service, the MA plan can create its own coverage policy, but all research and evidence must be publicly available.
MA plans must consider the individual patient’s personal circumstances and clinical presentation when making coverage decisions.
Prior authorization should only be used to confirm the presence of diagnoses or other medical criteria and to ensure that the furnishing of a service or benefit is medically necessary or, for supplemental benefits, clinically appropriate. Prior authorization should not function to delay or discourage care.
MA organizations must establish a Utilization Management (UM) Committee that would be responsible, at least annually, for reviewing the policies and procedures for all utilization management techniques and policies used by the MA plan, including prior authorization.

Health Equity

In an effort to ensure equitable access to MA services, CMS broadened the categories of patients for which MA plans must provide services in a culturally competent manner to include individuals:

with limited English proficiency or reading skills;
of ethnic, cultural, racial, or religious minorities;
with disabilities;
who identify as lesbian, gay, bisexual, or other diverse sexual orientations;
who identify as transgender, nonbinary, and other diverse gender identities, or people who were born intersex;
who live in rural areas and other areas with high levels of deprivation; and
otherwise adversely affected by persistent poverty or inequality.

In addition, CMS now requires that MA provider directories include providers’ cultural and linguistic capabilities (including American Sign Language, ASL) under this final rule.

Background

ASHA has heard reports from our members and other stakeholders, including organizations representing beneficiaries and other clinical specialties, that prior authorization and other utilization management techniques have created significant hurdles to care for Medicare patients. These barriers create an inequitable system for patients depending on whether they were covered by traditional Medicare or an MA plan because utilization management policies are often based on proprietary guidelines that do not align with Medicare coverage guidelines.

What’s Next

The new regulations are an important step forward in clarifying MA coverage guidelines and ensuring patient access to care. It addresses many of the concerns raised in a 2022 report by the Department of Health and Human Services Office of Inspector General, which called out potentially inappropriate practices on the part of MA organizations. ASHA remains committed to ensuring coverage policies developed by all payers are based on the evidence, research, clinical judgment of audiologists and speech-language pathologists, and the unique clinical presentation of the patient. We will continue to monitor the implementation of these regulations and engage CMS, as appropriate, to refine these policies to meet the needs of our members and the patients they treat.