CMS rule cracks down on prior authorization requirements in MA plans

Medicare Advantage (MA) plans will find it harder to require prior authorizations for their coverage under a new final rule from the Centers for Medicare and Medicaid Services (CMS).

CMS says the new rule, announced April 5, is intended to address MA member complaints that plans’ prior authorization requirements restrict their access to care. In response, the rule will:

• limit the use of coordinated care MA plans’ prior authorization policies to confirming the presence of diagnoses or other medical criteria and/or ensuring that an item or service is medically necessary,
• prohibit coordinated care MA plans from requiring prior authorizations for an active course of treatment for...