Navigating the intricate landscape of Medicare can be daunting, particularly when it comes to prior authorization rules. Recognizing these complexities, the Centers for Medicare & Medicaid Services (CMS) have introduced the 2024 Medicare Advantage and Part D Final Rule CMS-4201-F. 

This groundbreaking rule aims to untangle and simplify these intricate processes, aligning Medicare Advantage with Original Medicare to make medically necessary care more accessible.

In this article, we will explain these changes and what they mean for those relying on Medicare.

Does Medicare require prior authorization?

Medicare Part A and Part B have historically had minimal prior authorization rules. The initial structure of the Social Security Act didn’t include “prior authorization” for Medicare services. However, subsequent legal amendments allowed for prior authorization, specifically for limited items like Durable Medical Equipment and certain physicians’ services. Yet, even with these amendments, Original Medicare continues to have few services that mandate prior authorization.

On the other hand, Medicare Advantage (MA) plans frequently require prior authorization for various services, including visits to specialists, out-of-network care, non-emergency hospital care, and more. These requirements can differ between MA plans, so enrollees should reach out to their specific plan for detailed information on when and if prior authorization is needed.

Furthermore, Medicare Prescription Drug (Part D) Plans often impose prior authorization to provide coverage for particular drugs. Again, it is essential to contact the plan to understand the specific rules and requirements.

When confused, physicians often use a Medicare prior authorization list or Medicare prior authorization lookup tools to confirm whether an item, procedure, or visit requires prior authorization.

Medicare Advantage prior authorization: new rules

Here’s a detailed breakdown of the new rules detailed in CMS-4201-F regarding Medicare Advantage Prior Authorization:

Continuity of granted prior authorization approvals

Under the 2024 Medicare Advantage and Part D Final Rule, a granted prior authorization approval must remain valid as long as it is medically necessary. This ensures that enrollees will not experience any disruptions in their care, enabling a smoother and more consistent experience for patients.

Annual review of utilization management policies

Medicare Advantage (MA) plans are now required to conduct an annual review of their utilization management policies. This fosters a continual examination and refinement of policies to better align with the needs and health outcomes of the enrollees.

Denials of coverage review

Any denial of coverage based on medical necessity must now be reviewed by healthcare professionals with relevant expertise. This additional level of scrutiny ensures that the denial process is fair and grounded in medical expertise.

Alignment with traditional Medicare coverage criteria

CMS has clarified rules concerning acceptable coverage criteria for basic benefits. MA plans must now align with national and local coverage determinations (NCD, LCD) and general Traditional Medicare regulations. In cases where coverage criteria are not fully defined, MA organizations can create internal criteria based on current evidence, subject to transparency requirements.

Streamlining prior authorization requirements

The final rule adds continuity of care requirements and aims to reduce disruptions for beneficiaries. Key elements include:

• Limiting the use of prior authorization policies in coordinated care plans to specific medical criteria.
• Providing a 90-day transition period for enrollees switching to a new MA plan.
• Establishing a Utilization Management Committee within all MA plans to review policies annually.
• Clearly defining the duration of a “course of treatment” for prior authorization to ensure uninterrupted care.

Building upon CMS’ advancing interoperability

The recommendations above are an extension of CMS’ earlier proposal (CMS-0057-P), which suggested several measures to improve the prior authorization process:

• Implementing an Application Programming Interface (API) to streamline the process.
• Responding to prior authorization requests within specific timeframes.
• Clearly stating the reason for any prior authorization denials.
• Publicly reporting on prior authorization approvals, denials, and appeals.

How long does it take for prior authorization to come into effect?

The timeline for Medicare prior authorization to come into effect can vary, typically ranging from several days to a week. This process is crucial for obtaining coverage for medical equipment, prescription medication, and other essential treatments and services under Medicare. It is advisable to contact your pharmacy promptly if you require Medicare’s preauthorization for medically necessary prescription drugs. 

The time taken to secure prior authorization may differ based on various factors including the way Medicare prior authorization forms are submitted and the specific requirements of the service needed. Unfortunately, this process can sometimes lead to delays or even outright denials. Hence, understanding the guidelines and acting swiftly can be vital in ensuring that there are no unnecessary interruptions in accessing the care or medications needed.

Bottomline

The changes to Medicare Advantage and Part D’s prior authorization rules in the 2024 Final Rule CMS-4201-F reflect a significant shift towards streamlining and enhancing the process. By implementing new requirements and clarifications, CMS aims to reduce disruptions, increase transparency, and ensure that Medicare Advantage enrollees have consistent access to medically necessary care. 

These reforms echo the growing emphasis on patient-centered care and the importance of coordination between healthcare providers and insurance plans. Beneficiaries and healthcare providers alike should be aware of these changes to navigate the system effectively and utilize the medical services and support available to them.