New Prior Authorization Rule Aims to Quicken Senior Access to Care

Building on previous interoperability regulations, CMS on Dec. 13 published a proposed rule that seeks to improve the efficiency and transparency of prior authorization processes in Medicare Advantage and other federally funded health care programs. Industry experts say the rule should ultimately speed access to care, potentially alleviating some but not all of the concerns expressed by providers, patient advocates and lawmakers about the burden of prior authorization, particularly on seniors.

In issuing the proposed rule, the agency said it withdraws and replaces a previously proposed rule (CMS Interoperability and Prior Authorization Proposed Rule, 85 Fed. Reg. 82586), and addresses public comments received on that rule. Published in December 2020, the aforementioned rule proposed to place new requirements on Medicaid and Children’s Health Insurance Program managed care plans, state Medicaid and CHIP fee-for-service programs, and Qualified Health Plan (QHP) issuers to improve the electronic exchange of health care data, and streamline processes related to prior authorization. The rule included five sets of proposals and five requests for information but did not specifically apply to MA.