Medicare Makes Changes to Rules Regarding Prior Authorization for Advantage & Part D Plans

On April 5th, 2023, the Centers for Medicare & Medicaid Services (CMS) finalized a proposed rule intended to streamline the process used to authorize care and make other important changes to Medicare Advantage and Medicare Part D plans. As these changes are implemented, it should make it easier for Medicare recipients to get the care they need without the requirement to have each treatment authorized individually.

What is Prior Authorization?

Medicare Advantage plans and Medicare Part D plans require authorization to obtain coverage for certain procedures and drugs. For example, a Medicare Advantage recipient might need prior authorization to see a specialist or a Medicare Part D recipient might need prior authorization to cover specific prescription drugs. In contrast, traditional Medicare requires prior authorization for very few procedures. In the past, Medicare Advantage and Medicare Part D recipients would often have to wait for authorization at multiple stages of their treatment, costing them time and effort. The rules are now being updated to make Medicare Advantage and Part D prior authorization requirements more consistent with those of traditional Medicare.

Changes to Medicare Prior Authorization

With the April rule change, prior authorization for Medicare Advantage and Part D plans will be made simpler. Essentially, once a doctor authorizes a specific course of treatment that is approved, the patient will require no further authorizations for any procedures, appointments, or drugs required to complete that course of treatment. Additionally, any Medicare Advantage plan member who switches plans during treatment will not be required to undergo any new authorizations for 90 days after switching.

CMS will also be requiring all Medicare Advantage plans to review their policies annually regarding coverage decisions and guidelines. They will be compared to authorization requirements for traditional Medicare and updated to be consistent with them, as necessary. This will make it easier to determine what types of treatments will be covered, preventing any delays in care for patients during their treatment period.

Other Changes to Medicare Advantage & Part D Plans

CMS also previously proposed numerous other changes, most of which have already been finalized. 

These include:

  • Preventing Misleading Marketing – Medicare Advantage plan advertisements must now mention a specific plan name, rather than marketing Medicare Advantage plans in general terms. Ads must also refrain from using words or imagery that may confuse beneficiaries or from using Medicare logos in a way that is misleading.
  • Star Ratings Program – Medicare Advantage and Part D plans will now be rated with a star system to better address patient experiences and complaints. CMS hopes this rating system will motivate plans to improve patient experiences in the future.
  • Advancing Health Equity – CMS hopes to provide better care for underserved populations by clarifying current rules regarding care requirements for people who have been marginalized in the past. These include those with limited English proficiency, members of cultural, ethnic, religious, or racial minorities, people with disabilities, members of the LGBTQ+ communities, those who live in rural areas, and those who are affected by persistent poverty or inequality.
  • Improving Access to Behavioral Health – Network standards will now be set for clinical psychologists and licensed clinical social workers. Access to behavioral health services will be expanded, and emergency behavioral health services will not be subject to prior authorization.

These are just a few of the 22 proposed rule changes which are currently being finalized. When these rule changes are finalized, they will be documented in the Federal Register here. If you are currently enrolled in Medicare Advantage or Part D, or you plan to enroll in the future, be sure to stay apprised of any rule changes so you can make the best decisions about your care.

If you have any questions about Medicare, Medicaid, or any other elder law concerns, it is important you speak with an experienced elder law attorney right away. As one of the first dedicated elder law attorneys serving Bucks County, PA, and neighboring counties, Robert Slutsky is highly qualified to advise you about Medicaid asset protection, estate planning, powers of attorney, and more. Contact Rob today to prepare yourself for the future. Call (610) 940-0650 today or visit our contact page to inquire about setting up a consultation with a trusted elder law attorney serving Philadelphia, PA, and surrounding counties.

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