CMS Advancing Interoperability and Improving Prior Authorization Final Rule (CMS-0057-F)

Key features of the Interoperability and Patient Access final rule included:

• Patient Access API: By January 1, 2027, payers must add information about prior authorizations (excluding those for drugs) to the data available via that Patient Access API for the purpose of giving patients access to more of their data, and helping patients understand their payer’s prior authorization process and its impact on their care.
• Provider Access API: By January 1, 2027, payers must implement and maintain a Provider Access API to share patient data with in-network providers with whom the patient has a treatment relationship
• Payer-to-Payer API: By January 1, 2027, make available claims and encounter data, data classes and data elements in the USCDI and information about prior authorizations (excluding those for drugs) – all to help improve care continuity when a patient changes payers and ensure that patients have continued access to the most relevant data in their records.
• Prior Authorization API: By January 1, 2027, payers must implement and maintain a Prior Authorization API that is populated with its list of covered items and services, can identify documentation requirements for prior authorization approval, and supports a prior authorization request and response.

In addition, the Final Rule created guidelines to Improve Prior Authorization Processes, requiring payers to follow new Prior Authorization rules by January 1, 2026, including:

• Send prior authorization decisions within 72 hours for expedited requests and seven calendar days for standard requests
• Provide a specific reason for denied prior authorization decisions, regardless of the method used to send the prior authorization request
• To publicly report certain prior authorization metrics annually by posting them on their website

CMS Interoperability and Prior Authorization Final Rule CMS-0057-F

• View the rule in the Federal Register

Let the Medicare Advantage lobbying begin

If there’s one thing to take away from CMS’ newest proposals for Medicare Advantage plans, it’s that the Biden administration didn’t really want to rock the boat in an election year.

CMS expects the average benchmark payment for MA plans to decrease by 0.2% in 2025, the agency said Wednesday. But that doesn’t mean MA plans will be paid less next year (keep this in mind if insurers and Republicans falsely claim, again, that this is a “cut” to Medicare benefits). After accounting for the industry’s intensive coding practices, which are lumped on top of that benchmark payment and vary from insurer to insurer, Medicare still expects to pay MA plans an extra $16 billion compared with this year.

— STAT, February 5, 2024

Government warns Medicare Advantage insurers not to deny care based on AI.

In recent months, the federal government has repeatedly told Medicare Advantage insurers that they cannot use artificial intelligence or algorithms to deny medical services the government routinely covers.

But in finalizing a rule to that effect, it also stepped into a thicket of questions from insurers about a technology that is especially difficult to pin down: What is AI? Can it be used at all to make decisions about the coverage of older patients? If so, how?

— STAT, February 7, 2024

CMS pledges to use ‘full array’ of tools to enforce 2024 Medicare Advantage rules

“Key decision makers” at the Centers for Medicare & Medicaid Services assured a coalition of industry leaders that “they intend to use their full array of tools” to ensure the MA plans stick to rule changes, according to Nicole Fallon, vice president of integrated services and managed care at LeadingAge.

CMS intended the rule changes, which went into effect Jan. 1, to broaden protections under MA — including clarifying coverage rules, limiting plan denials and restricting when technology could be used to make decisions about ending coverage. But associations and consumer advocates saw worrying signs that MA plans were unlikely to significantly change their policies in reaction to the rules.

— McKnight’s Long-Term Care News. Jan 12, 2024

CMS finalizes long-awaited prior authorization rule for Medicare Advantage – McKnight’s Long-Term Care News

Lawmakers and providers alike have asked CMS to change MA rules throughout the past year in order to lessen the financial burden on long-term care providers and Medicare patients. 

“Impacted payers must provide a specific reason for denied prior authorization decisions regardless of the method used to send the prior authorization request,” the fact sheet confirms. “This requirement is intended to both facilitate better communication and transparency between payers, providers, and patients, as well as improve providers’ ability to resubmit the prior authorization request, if necessary.”

— McKnight’s Long-Term Care News. Jan 18, 2024

Medicare Advantage plans intent on skirting new rules, providers fear.

Aging services providers are increasingly concerned that powerful Medicare Advantage plans will not fall into line under new federal rules, which were once seen as the possible beginning of a tide change for beneficiary rights.

Changes to Medicare Advantage slated to kick in Jan. 1 were designed to ensure plans extend their enrollees the same benefits and coverage as available to traditional Medicare beneficiaries. Specific revisions outline how MA plans could make coverage determinations, limit their use of denials and prior authorization, and place new limits on the use of digital technologies in deciding when covered care ends.

— McKnight’s Long-Term Care News. December 1, 2023