Medicare Advantage Proposal Aims to Curb Prior Authorization Abuses, Improve Equity

February 14, 2023

The Association for Clinical Oncology (ASCO) submitted comments in response to the Centers for Medicare & Medicaid Services (CMS) Contract Year 2024 Policy and Technical Changes to the Medicare Advantage (MA) and Medicare Prescription Drug Benefit Programs proposed rule. ASCO’s comments focus heavily on the proposed changes to prior authorization in the MA program in addition to enhancing health equity and other updates to the Part D drug benefit program.

Prior Authorization

CMS is proposing changes to prior authorization requirements in MA in response to an April 2022 report from the Office of the Inspector General that found abuses of prior authorization practices in the program. The proposals aim to ensure people enrolled in MA plans have access to the same services as those in Traditional Medicare. ASCO commends CMS for taking initial action to address the concerns around prior authorization, utilization management, and medical necessity determinations in MA, and offers recommendations, including:

  • ASCO supports CMS’ proposals to codify standards for coverage criteria to ensure that basic benefits coverage for MA enrollees is no more restrictive than for traditional Medicare beneficiaries and to require plans to establish a utilization management committee to ensure compliance
  • ASCO supports the proposal that absent an applicable Medicare statute, regulation, national coverage determination, or local coverage determination for coverage, MA organizations must include current evidence from widely used treatment guidelines or clinical literature when creating internal clinical coverage criteria
  • ASCO recommends that its guidelines be included in establishing clinical coverage criteria and that prior authorization should not be required for pathway and/or guideline concordant care
  • ASCO strongly supports CMS’ proposal to make a prior authorization approval valid for the duration of the approved course of treatment and/or the duration of the prescribed order
  • With CMS proposing a minimum 90-day transition period when an enrollee switches plans, ASCO recommends that the agency prohibit mandatory substitution or interruptions in treatment that is already underway
  • ASCO urges CMS to require payers to ensure that during “peer-to-peer” or other discussions of clinical circumstances, the treating oncologist has direct access to another oncologist employed (or otherwise authorized) by the payer to make prior authorization determinations in cancer care

Health Equity

CMS also proposed requirements for MA plans to address and improve health equity in the program. ASCO applauds the agency’s efforts to address and reduce health disparities through policy updates and changes in its proposal. Specifically, ASCO supports proposals that would require MA plans to:

  • Provide culturally competent care to an expanded list of populations adversely affected by persistent poverty or inequality
  • Identify and offer digital health education to enrollees with low digital health literacy to assist them with accessing any medically necessary, covered telehealth benefits
  • Incorporate one or more activities into their overall Quality Improvement (QI) program that reduce disparities in health and health care among enrollees

Read the full comment letter.

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