CMS MA and Prescription Drug Coverage Proposed Rule Includes Prior Authorization Requirement
November 7, 2023
The Centers for Medicare & Medicaid Services (CMS) released a proposed rule in an effort to strengthen Medicare Advantage (MA) and the Medicare Prescription Drug Benefit Program (Part D). The proposed rule includes provisions seeking to improve transparency on the effects of prior authorization on underserved communities.
To drive this, CMS is proposing to require that MA plans include an expert in health equity on their utilization management committees and that the committees conduct an annual health equity analysis of the plans’ prior authorization policies and procedures. This analysis would examine the impact of prior authorization on enrollees with one or more of the following social risk factors—eligibility for Part D low-income subsidies, dual eligibility for Medicare and Medicaid, or having a disability—compared to enrollees without these risk factors. These analyses would have to be posted publicly to improve transparency into the effects of prior authorization on underserved populations.
In addition, the rule proposes to: (i) protect people with Medicare and promote a competitive marketplace in MA by adding guardrails to plan compensation for agents and brokers, including standardization; (ii) improve access to behavioral health care by adding a new facility type that includes several behavioral health provider types to Medicare Advantage network adequacy requirement; (iii) implement policies to increase the utilization and appropriateness of supplemental benefits; and (iv) increase flexibility for Part D plans to more quickly substitute lower cost biosimilar biological products for their reference products.
Comments are due to CMS by January 5, 2024. Go here to access a fact sheet on the proposed rule.