2024 Medicare Advantage Rule-making Shows AAFP Advocacy

Proposed Rule Would Bring Wins on Prior Authorization, Health Equity

Feb. 22, 2023, News Staff — The AAFP’s push for administrative simplification gained substantial ground in a proposed rule for 2024 that would overhaul aspects of Medicare Advantage and Part D plans in line with long-standing Academy advocacy.

In a Feb. 13 letter to HHS and CMS, the Academy recognized that the rule, if finalized, would “improve access to behavioral health services in MA and address barriers to care caused by prior authorization.”

In tandem with upcoming meetings between the Academy and Medicare Advantage CMS staff — as well as with two letters in which the AAFP joined scores of other medical and health care organizations in reacting to the proposed rule — the Feb. 13 correspondence offered detailed guidance on improving the rule before it becomes final.

Background

CMS annually issues a rule to modify regulations for Medicare Advantage and Part D plans, which are administered by insurance companies and other third parties. Prior authorization processes are among the areas addressed in the rule, although Medicare Advantage plan administrators may issue additional, often more restrictive, clinical criteria affecting prior authorizations.

The resulting burdensome prior authorization process hurts many Medicare beneficiaries in Medicare Advantage plans, which enrolled more than 28 million people last year. In fact, an April 2022 HHS report found that, among prior authorization requests that Medicare Advantage plans denied in 2019, 13% actually had met Medicare coverage rules

The MA rule for 2024 aims to reduce inappropriate care denials while simplifying administrative processes for physicians — both substantial wins for the Academy’s longtime advocacy for prior authorization reform in MA, including through legislation.

The AAFP’s letter urged CMS to finalize elements of the rule that would

improve MA coverage criteria, increase transparency of prior authorization and medical necessity determinations and prevent inappropriate coverage denials by MA organizations;
strengthen MA network adequacy requirements and standards related to behavioral health;
codify appointment wait-time standards for primary care and behavioral health services in MA; and
require implementation of the Real Time Prescription Benefit standard to make prescription drug coverage information available to the prescribing physician at the point of care.

Story Highlights

Opioid Use Disorder

The AAFP supports the rule’s proposal to clarify that behavioral health care could be provided on an emergency basis and therefore could not be subject to prior authorization, and recommended applying this clarification to opioid use disorder treatment.

The Academy also said CMS should encourage MA organizations to implement policies, procedures and clinician payment structures that support integration of behavioral health in the primary care setting.

Equitable Care Access

The proposed rule’s plan to solidify health-equity guardrails by ensuring that MA organizations cannot deny coverage or service “based on internal, proprietary or external clinical criteria not found in traditional Medicare coverage policies” is a win for the Academy’s advocacy, and the letter expressed strong support for it.

“We are hopeful that these proposals will advance equitable access to care and transparency in MA coverage policies,” the letter said.

The AAFP urged greater specificity, however, in the proposed rule’s “expectation” that MA organizations would “make medically necessary decisions in a manner that most favorably provides access to services for beneficiaries and aligns with CMS’ definition of ‘reasonable and necessary.’”

“We wholeheartedly agree that MA organizations should make medical necessity determinations with the goal of providing access to services, including by ensuring physicians and other care providers are paid in a fair and timely manner,” the Academy wrote. “We are concerned that some MA organizations may increase claim and payment denials after the implementation of new prior authorization requirements and regulations. The AAFP encourages CMS to reiterate this expectation in manuals and other program guidance for MA organizations and conduct oversight to prevent an uptick in claim denials if and when these proposals are finalized and implemented.”

The Academy made several recommendations responding to part of the rule proposing to allow MA plans to create internal coverage criteria based only on current evidence in widely used treatment guidelines or clinical literature that is made publicly available when no applicable Medicare statute or guideline establishes whether an item or service must be covered. Under the rule as written, MA plans would have to post a publicly accessible summary of the evidence used and rationale that supports the coverage criteria.

“The AAFP strongly supports proposals to make criteria for medical necessity and coverage determinations more transparent and clinically valid,” To further strengthen this part of the proposed rule, the Academy urged CMS to

apply it to prescription drugs and Part D plan sponsors;
require MA organizations to make summaries and explanations of medical necessity and coverage determination policies prominent and easy to find online;
require MA organizations to provide a link to the publicly available clinical criteria it used when denying a prior authorization request;
require MA organizations to provide potential enrollees with a link to its available coverage criteria summaries;
require MA plans to involve a physician of the relevant medical specialty in the development of medical necessity and clinical criteria policies it will use to approve or deny coverage of services.

Expounding on that last point, the letter called on CMS to “require MA organizations to consult with a physician of the relevant medical specialty when developing policies for prior authorization and making individual medical necessity determinations across various services and conditions.” MA plans also should consult a physician of the relevant specialty when reviewing prior authorization requests, the AAFP said.

“Family physicians regularly report that existing prior authorization processes, including those that require them to have a peer-to-peer consultation with another physician, are often dictated by physicians employed by insurers who do not have the requisite expertise to make decisions about patient care,” the letter said, noting that this “results in erroneous denials, lengthy patient care delays, and additional time spent submitting appeals.”

Prior Authorization

The Academy objected to part of the proposed rule that would add allow prior authorization processes to be applied to basic benefits and supplemental benefits when “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 and should not function to delay or discourage care.”

“The AAFP opposes the proposal to provide in new regulations that a coordinated care plan may use prior authorization for basic benefits and supplemental benefits,” the letter said, noting that CMS’ examples of allowable prior authorizations in the proposed rule would in fact be “likely to delay and discourage care.”

Family physicians often wait too long for prior authorization — even simply to confirm the presence of a diagnosis or other criteria — which delays patient care, the letter noted.

“Physicians undergo years of medical training to learn how to properly diagnose conditions and create care plans in consultation with their patients,” the AAFP wrote. “Prior authorization requirements to confirm these diagnoses are unnecessary and, unless a decision is provided in real time, will always function to delay care.”

The Academy called on CMS to

put more guardrails on the volume of prior authorization requirements that can be imposed (such as limits on the use of prior authorization for certain benefit categories or low-cost services);
outline explicit requirements for MA organizations to respond to prior authorization requests in 24 hours for urgent requests and 48 hours for non-urgent requests;
encourage MA plans to develop programs and exception policies that limit the volume of prior authorization for services that are considered standard of care; and
expand the rule’s prior authorization proposals to prescription drugs and Part D plan sponsors.

To emphasize this advocacy, the Academy added its voice to a Feb. 13 letter to CMS on the proposed rule that was signed by dozens of medical and specialty groups.

“We are pleased that CMS is encouraging MA plans to implement gold-carding programs to exempt physicians with high approval rates from PA requirements,” that letter said. “We encourage CMS to establish a requirement on MA plans to develop such programs. We urge CMS to further strengthen its PA reform effort by extending its proposed clinical validity and transparency of coverage criteria polices into the area of prescription drugs.”

As a member of the Regulatory Relief Coalition, the Academy echoed this advice alongside numerous co-signatories in another Feb. 13 letter outlining ways in which CMS should refine the rule before it’s finalized.

Relatedly, the Academy is reviewing a CMS proposed rule that would begin standardizing electronic prior authorization processes across payers, and expects to send comments in the coming weeks.