Protecting Patient Care with Enhanced Medicare Advantage Oversight and Prior Authorization Changes

Currently, nearly 31 million people are enrolled in a Medicare Advantage plan, accounting for slightly more than half of America’s eligible Medicare population.

For many people, choosing an MA plan is a life-changing event and a significant act of trust, counting on the payer they selected to provide the pre-agreed upon coverage for either current medical needs or those that may arise.

The good news is that some MA plans live up to their responsibility to support patient care and access. The bad news is that not all of them do, including some of the largest commercial insurers who provide coverage to millions of Medicare beneficiaries across the nation.

There have been many alarming stories from patients across the nation who report crashing into inappropriate barriers to the care they need, as their MA providers use prior authorization requirements in a manner that leads to dangerous delays in treatment, clinician burnout and waste in the health care system.

While prior authorization can be a tool to help ensure patients receive coverage for their care, too often the practice has been misused by these large commercial insurers to impose bureaucratic obstacles and create mountains of paperwork and red tape for providers, often jeopardizing patient health in the process.

Addressing abuses of prior authorization has been a top AHA priority. We have been working on many fronts to push back against these practices, as well as other MA plan abuses, and have repeatedly urged the Centers for Medicare & Medicaid Services to address these important issues.

We’re pleased to report that CMS has listened and acted. The agency this week issued a final rule requiring MA, Medicaid, Children's Health Insurance Program and federally facilitated Marketplace plans to streamline their prior authorization processes to improve timely access to care for patients and alleviate provider administrative burden. We appreciate the agency’s efforts to improve patient access to care and help clinicians focus on patient care rather than paperwork.

On Wednesday, CMS Administrator Chiquita Brooks-LaSure visited Inova Fairfax Medical Campus in Virginia for a tour and roundtable discussion featuring hospital leaders and AHA staff. The CMS leader heard from doctors and patients about how certain prior authorization practices are negatively affecting patient care and why these actions are necessary. We are grateful to Stephen Jones, M.D., president and CEO of Inova, for providing a forum for this important and timely conversation.

We appreciate the progress on this issue, and the AHA continues to engage policymakers to increase oversight of the MA program overall to improve how coverage works for MA enrollees. Specifically, we have asked regulators to examine instances where MA plans apply their own coverage criteria that is more restrictive than Traditional Medicare, resulting in inappropriate denials of medically necessary care and disparities in coverage between beneficiaries in MA and those in the Traditional Medicare program.

The agency’s contract year 2024 MA final rule, which went into effect Jan. 1, represented progress on several fronts. When fully implemented, these policies should promote more timely access to care, more closely align coverage between Traditional Medicare and MA, and increase oversight of MA plans.

To help hospitals and health systems understand and hold MA plans accountable for policy changes under that final rule, we recently published a guide that includes leading practices for monitoring MA plan compliance, FAQs and other resources.

We will continue to work with CMS, Congress and others to make sure all Medicare beneficiaries can access the care they need.