CMS is proposing revisions to the required metrics for the annual health equity analysis of the use of prior authorization. Under the proposed changes, MA organizations would have to report the metrics for the analysis by each item or service, rather than in aggregate. This change would allow CMS and MA organizations to more readily identify trends related to the use of prior authorization and, therefore, be able to more fully identify and address the impact of prior authorization on enrollees with specified social risk factors.    

This proposal is part of a proposed rule published by the Centers for Medicare & Medicaid Services (CMS) on November 26, 2024, entitled “Medicare and Medicaid Programs; Contract Year 2026 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicare Cost Plan Program, and Programs of All-Inclusive Care for the Elderly.”  

More specifically, CMS is proposing to revise 42 CFR Section 422.137(d)(6)(iii)(A) through (H) to require the following:  

• The percentage of standard prior authorization requests that were approved, reported by each covered item and service.    
• The percentage of standard prior authorization requests that were denied, reported by each covered item and service.    
• The percentage of standard prior authorization requests that were approved after appeal, reported by each covered item and service.   
• The percentage of prior authorization requests for which the time frame for review was extended, and the request was approved, reported by each covered item and service.    
• The percentage of expedited prior authorization requests that were approved, reported by each covered item and service.    
• The percentage of expedited prior authorization requests that were denied, reported by each covered item and service.    
• The average and median time that elapsed between the submission of a request and a determination by the MA plan, for standard prior authorizations, reported by each covered item and service.    
• The average and median time that elapsed between the submission of a request and a decision by the MA plan for expedited prior authorizations, reported by each covered item and service. 

This rule will impact Medicare Advantage (Part C) organizations, Medicare Prescription Drug Benefit (Part D) sponsors, and Programs of All-Inclusive Care for the Elderly (PACE) and was recently published in the Federal Register.  

Comments must be received by January 27, 2025.  

Categories: DATA ACCESS & INTEROPERABILITY

Tags: 2026 MA Rule, health equity, Medicare Advantage, prior authorization