In 2023, the Centers for Medicare & Medicaid Services (CMS) finalized prior authorization policy updates within Medicare Advantage (MA) in response to the Association for Clinical Oncology (ASCO) and other stakeholder concerns that prior authorization processes limit beneficiary access to care in Medicare Advantage. The table below highlights updates to prior authorization in the MA program only, that went into effect on January 1, 2024.
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Medicare Advantage |
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Effective Date: January 1, 2024 |
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Alignment with Traditional Medicare |
Continuity of Care |
Utilization Management Committee |
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MA overage must align with national coverage determinations, local coverage determinations, Medicare Manuals, and guidance for Traditional Medicare |
Prior authorization approval applies to the entire course of treatment and as long as medically necessary |
All MA organizations must establish utilization management committees to review prior authorization policies annually |
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Prior authorization can only be used to confirm diagnosis or medical necessity, not to limit coverage |
Plans should work with providers to assess continued efficacy and medical necessity for indefinite drug use |
Led by a Medical Director |
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Emergency, urgent, stabilization, and out of network services are not subject to prior authorization |
Prior authorization cannot be required for a minimum of 90-days for those in active treatment when switching plans |
Majority of members to be physicians, one elderly/disabled expert, representing multiple specialties |
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Before a denial can be issued, someone with “relevant medical expertise” must review the request |
Must review prior authorization policies annually |
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In December 2023, CMS announced plans to audit MA and Medicare Part D in 2024 to ensure that MA plans are following the new prior authorization requirements. CMS expects to perform audits on utilization management practices tied to 88% of people with MA. Please reach out to ASCO staff if you are concerned that plans are not adhering to the new prior authorization requirements.
In January 2024, CMS finalized additional provisions to streamline the prior authorization process for MA, Medicaid Managed Care and Fee for Service, Children’s Health Insurance Plans (CHIP) Managed Care and Fee for Service, and Qualified Health Plans (QHPs) on the Federally Facilitated Exchanges (FFEs). The provisions in the next two tables apply to those plans, but exclude all prescription drugs.
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Medicare Advantage, Medicaid Managed Care and Fee for Service, CHIP Managed Care and Fee for Service, QHPs |
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Application Programming Interface (API) Requirements Effective: 2027 |
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Excludes drugs. Applies only to items and Services |
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Patient Access API |
Provider Access API |
Payer to Payer API |
Prior Authorization API |
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Must include claims, encounter, clinical and prior authorization data |
Must include claims, encounter, and prior authorization data |
Must include claims, encounter, and prior authorization data |
Must include services requiring prior authorization and necessary documentation |
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Usage metrics to be posted in 2026 |
Data exchange between in-network providers with a treatment relationship |
Previous payer must provide prior 5 years of patient data |
Requests submitted and responses received through this API |
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Patient opt-out |
Patient opt-in |
Connects to provider electronic health record |
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Medicare Advantage, Medicaid Managed Care and Fee for Service, CHIP Managed Care and Fee for Service, QHPs |
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2026 – Prior Authorization (regardless of method) Requirements Effective: 2026 |
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Excludes drugs. Applies only to items and Services |
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Expedited Requests |
Standard Requests |
Reason for Denial |
Prior Authorization Transparency |
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72 hours |
7 days |
Payer must give specific reason for denial |
Listed on payer website |
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(except QHPs) |
Aggregated data on % of approvals, denials, appeals, timeframes |
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