CMS proposes new Medicare Advantage and Part D reforms on prior authorization, marketing

CMS proposed to clarify when and how MA plans can use prior authorization, where an insurer must approve items or services before a physician can dispense them. The rule would clarify that a granted prior authorization approval shall remain valid for “an enrollee’s full course of treatment, requiring MA plans to annually review utilization management policies and requiring coverage determinations be reviewed by professionals with relevant experience,” according to a release. 

If an item or service doesn’t have an applicable coverage determination from Medicare, then an MA plan must “include current evidence in widely used treatment guidelines or clinical literature made publicly available to CMS, enrollees and providers when creating internal clinical coverage criteria,” according to a fact sheet on the rule.

Any physician or expert used by the MA plan must also have expertise in the field of medicine that “is appropriate for the service to be involved before the MA plan can deny coverage,” CMS added. 

Source: https://www.fiercehealthcare.com/payers/cms-proposes-new-medicare-advantage-and-part-d-reforms-prior-authorization-marketing