The CMS final rule simplifies prior authorization requirements for Medicare Advantage plans by requiring coordinated care plans to only use prior authorization to confirm diagnoses or medical criteria and ensure medical necessity. Additionally, plans must provide a 90-day transition period for enrollees switching plans while undergoing treatment, during which prior authorization cannot be required. All MA plans must establish a Utilization Management Committee to review policies annually, and prior authorization requests must be approved for the duration of the course of treatment as deemed medically necessary.

Last year NY time published an article citing a recent report by the inspector general’s office of the Health and Human Services Department that has found tens of thousands of people enrolled in private Medicare Advantage plans are being denied necessary care that should be covered under the program. The report highlights that these private insurance plans, which offer benefits to 28 million older Americans, require stronger oversight to increase enforcement against plans with a pattern of inappropriate denials. The report reviewed 430 denials in June 2019, finding that 13% of the requests denied should have been covered under Medicare. The investigators estimated that as many as 85,000 beneficiary requests for prior authorization of medical care were potentially improperly denied in 2019. Furthermore, about 18% of payments were denied despite meeting Medicare coverage rules, equating to an estimated 1.5 million payments for all of 2019. While the industry’s main trade group claims that people choose Medicare Advantage because it delivers better services, better access to care, and better value, federal investigators claim that plans are delaying or even preventing beneficiaries from getting medically necessary care. This report echoes similar findings by the office in 2018 showing that private plans were reversing about three-quarters of their denials on appeal.