Last week, the Biden administration finalized a prior authorization rule that, among other things, will require insurers offering Medicare Advantage plans to use an electronic prior authorization process, approve requests more speedily, and report on their prior authorization denials. But, the rule does not take effect for three years and still leaves people with urgent health care needs at risk of not getting timely care and suffering serious harm in Medicare Advantage.
(If you’re enrolled in Medicare Advantage, you should take advantage of the Medicare Advantage Open Enrollment Period, which end at the end of March, and study your Medicare options. Traditional Medicare has no prior authorization requirements, and you are covered for care anywhere in the US. Traditional Medicare also has no out-of-pocket cap, so it’s good to get supplemental coverage if you don’t have Medicaid. Supplemental plans K and L are lower cost.)
The Centers for Medicare and Medicaid Services’ (“CMS”) final prior authorization rule does not dictate when or how often insurers can use prior authorization, nor does it require insurers to disclose this information. And, it still allows insurers to take a week to make a determination on a standard prior authorization request and 72 hours on an urgent request. When people urgently need care, a 72-hour wait could literally kill them.
Moreover, the new prior authorization rule doesn’t apply to prescription drug coverage. Right now, some Medicare Advantage plans require people with diabetes to go through a prior authorization process each time they need a continuous glucose monitor, even though it is standard treatment.
Given that many insurers impose prior authorization rules that are not evidence-based and that can lead to serious harm to the most vulnerable patients, CMS should be establishing a standard set of prior authorization rules that Medicare Advantage plans can use. Standardizing prior authorization also would be a step towards helping people understand their Medicare options; people should know how often the MA plans will force them to go through prior authorization hoops when choosing between Traditional Medicare and Medicare Advantage as well as when choosing among Medicare Advantage plans.
Today, people choose Medicare Advantage plans with blindfolds on. The government does not allow them to meaningfully distinguish among plans, let alone protect them from plans that are bad actors. Denial rates in some MA plans are more than 25 percent, but no one knows which deny care inappropriately at high rates and which allow enrollees to get the care they need.
In sum, people can’t know whether a particular Medicare Advantage plan will make them go through mega hoops before they can receive urgently needed care or whether it will inappropriately deny critically needed care. Even with these prior authorization final rules in effect, they can’t know. That’s not meaningful choice, that’s Russian Roulette.
Here’s more from Just Care:
- Medicare Advantage plans denied two million prior authorization requests in 2021
- How prior authorization requirements in Medicare Advantage could threaten your health
- Prior authorization: How dangerous is it?
- OIG finds widespread inappropriate care denials in Medicare Advantage
- AHA warns Medicare oversight agency about dangers of Medicare Advantage
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