March 13, 2023

APMA submitted comments to CMS yesterday in response to CMS’ proposed rule addressing improving prior authorization for Medicare Advantage organizations, Medicaid managed care plans and state Medicaid agencies, CHIP managed care entities and agencies, and Qualified Health Plans (QHP) issuers on the Federally Facilitated Exchanges (FFEs). Among its comments, APMA was largely supportive of the proposed improvements, with the following recommendations and qualifications submitted:

• CMS should be mindful of creating additional burdens through verification processes that are possibly glitchy in the rollout or difficult to navigate for the provider due to lack of clear instruction or process;
• CMS should incorporate its own proposals from another recent proposed rule; “Medicare Program: Contract Year 2024 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicare Cost Plan Program, etc.,” in which it proposed to limit payers’ review of prior authorization requests to only confirm the presence of diagnoses or other medical criteria to determine whether or not the patient’s condition meets criteria for approval as well as require that payers should utilize specialists with appropriate expertise to review prior authorization requests;
• CMS should require more in-depth detail of prior authorization metrics from impacted payers to better identify unnecessary prior authorization utilization and address coverage gaps and improve patient outcomes.

Members can read the full comment letter, as well as previous comment letters at www.apma.org/CommentLetters. Contact the APMA Health Policy and Practice department at healthpolicy.hpp@apma.org with any questions or concerns.