CMS signals additional prior auth reforms for Medicare Advantage, prescription drugs

April 26, 2024
Area(s) of Interest: Advocacy 

The Centers for Medicare and Medicaid Services (CMS) recently suggested that the agency may implement additional prior authorization reforms in the Medicare Advantage program.

Recently, CMS Administrator Chiquita Brooks-LaSure said CMS was evaluating whether the agency needed to take further action to crack down on health plans’ use of prior authorization and signaled that prescription drugs were a potential area for action.

A U.S. Department of Health Human Services Office of Inspector General (HHS OIG) report from 2022 found that Medicare Advantage Organizations delayed or denied enrollees’ access to necessary services via prior authorization.

Following the 2022 OIG report, CMS implemented a number of meaningful prior authorization reforms to Medicare Advantage and Medicaid plans. These reforms, from regulatory changes finalized in April 2023 and January 2024, will decrease delays in care and prevent inappropriate denials. Both of the regulations were consistent with changes advocated for by the California Medical Association (CMA). CMS estimates that efficiencies introduced through these policies will save physician practices over $15 billion over a 10-year period.

"I think that we have taken some really important steps in our rules. We've done the rules that are broad across the industry and also specific to Medicare Advantage. But we want to continue to look and hear about how things are operating. I've been hearing a lot about prescription drugs," LaSure said.

CMA continues to work with Congress  on federal legislation to achieve our remaining prior authorization goals and we are urging CMS to include drugs.  CMA is also supporting state-level legislation to reform prior authorization to ensure that patients receive the care they need — when they need it.

Share Your Story

CMA physicians have staunchly advocated for prior authorization reform by sharing personal stories and stories from patients about harmful care delays and denials; speaking to local media about the need for prior authorization reform; and submitting video testimonies about the impact of prior authorization. Patient witnesses also shared harrowing testimony in legislative hearings and through media outlets about the devastating impacts prior authorization delays have had on their lives and their loved ones.

CMA urges physicians to continue to share stories about the harms of prior authorization delays – both from your own experiences and practices, as well as from your patients. Together, we can win this fight and create a better system that prioritizes patients over profits.


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