CMS Targets Prior Authorization, Marketing in Medicare Advantage Proposed Rule

The American Hospital Association (AHA) and Better Medicare Alliance (BMA) both support the agency's effort to improve Medicare Advantage (MA).

In an attempt to reform MA, CMS released a proposed rule that aims to streamline prior authorization, promote health equity, and curb deceptive marketing.

The Biden administration has shown a commitment to increasing oversight of MA plans and the proposed rule would better align MA with traditional Medicare with new provisions and policies.

Building on a separate proposal by CMS, the new rule strengthens prior authorization protections for patients and makes the administrative process more efficient. It would require that a granted prior authorization approval remain valid for an enrollee's entire course of treatment, require MA plans to annually review utilization management policies, and require coverage determinations be reviewed by professionals with relevant expertise.

The rule would also tackle misleading marketing by MA plans by prohibiting ads that don't mention a specific plan name, as well as ads that use words, imagery, language, or logos that can be confusing and deceptive. MA marketing has been scrutinized by lawmakers for using tactics that are harmful to beneficiaries.

Additionally, the proposed rule would put forward a health equity index for MA star ratings and implement a key provision of the Inflation Reduction Act to lower prescription drugs costs for low-income Medicare beneficiaries.

"From streamlining prior authorization to cracking down on misleading marketing, we are committed to ensuring that everyone can have peace of mind and get the health care they need," HHS Secretary Xavier Becerra said.

The AHA commended CMS for taking steps to increase oversight of MA plans.

"The AHA has previously raised concerns about the negative effects of certain Medicare Advantage practices and policies that have the potential to directly harm patients through unnecessary care delays or outright denial of covered services," the AHA stated. "CMS' proposed rule includes helpful provisions to ensure more consistency between Medicare Advantage and traditional Medicare by curtailing overly restrictive policies that can impede access to care and add cost and burden to the health care system."

Meanwhile, the BMA, an MA advocacy group, also showed their support for the proposed rule.

Mary Beth Donahue, president and CEO of BMA, said in a statement: "Better Medicare Alliance commends CMS's work on delivering a thoughtful, comprehensive proposed rule and appreciates the agency's engagement with stakeholders across the health care spectrum ahead of the rulemaking process."