It does seem like CMS is on a crusade to force Medicare Advantage Plans (MAPs) to be more like Medicare Fee-For-Service (FFS), right?

And in the latest move to provide consistency and transparency to all Medicare, Medicaid, and marketplace beneficiaries, CMS issued the Interoperability and Prior Authorizations Final Rule (CMS-0057-F). The Rule’s prior authorization mandates, which take effect in 2026, create explicit timelines and reporting requirements that will remove a lot uncertainty from the process.

Next Episode: Thursday, June 20, 2024

Prior Authorization Decision Times

In general, the Rule requires most targeted payers to send decisions for expedited prior authorization requests within 72 hours. They have seven calendar days to render decisions for non-urgent authorization requests.

While three days seems slow for urgent requests, it is a good starting point. The Rule contains other provisions, slated for 2027, that will standardize prior authorization transactions with healthcare providers. I suspect the turnaround requirements will get shorter as technology permits.

Unfavorable Decisions

CMS will require targeted plans to include denial reasons for all unfavorable authorization decisions beginning in 2026. This seems obvious, but I suppose the agency needed to be explicit. From an operational standpoint, this provision should:

  • Make it easier to determine if unfavorable decisions are compliant with CMS rules and regulations, and
  • Help suppliers communicate clearly with patients.

The Final Rule Targets MAPs and Other Federally Funded Insurance Payers

The Rule goes beyond the watchful eye CMS and federal watchdog agencies have had on MAPs for some time. CMS is addressing transparency and consistency for a much broader beneficiary population. As such, the prior authorization mandates apply to:

  • MAPs
  • Medicaid FFS and managed care plans.
  • Childrens’ Health Insurance Plan (CHIP) FFS and managed care plans.
  • Qualified Health Plans (QHPs) offered on federally facilitated exchanges.

Effective Dates

The prior authorization mandates are effective on January 1, 2026, for MAPs, Medicaid FFS, and CHIP FFS programs. For managed care plans and QHPs, the provisions apply to rating periods or plan years beginning on or after January 1, 2026.