On April 5, CMS finalized the Contract Year 2024 Medicare Advantage (MA) rule, which will increase transparency in the prior authorization process, reduce disruptions of care and improve coverage criteria guidelines used by MA plans. Starting January 1, 2024, MA plans will be required to:

• Follow traditional Medicare coverage NCD’s, LCD’s, statutes and regulations when making medical necessity determinations.
• Create publicly accessible internal coverage criteria based on current evidence or clinical literature when coverage criteria are not fully established.
• PA approvals must be valid for as long as medically necessary to avoid disruptions in patient care and provide a minimum 90-day transition period for when enrollees switch MA plans.
• PA requests must be reviewed by health care professionals with relevant expertise before a denial can be issued.
• Establish a Utilization Review committee, led by the plan’s medical director, to review their utilization management policies annually.

The final rule also requires MA plans to develop and maintain procedures to identify and offer digital health education to enrollees to improve access to telehealth. Additionally, MA organizations will be required to incorporate one or more activities that reduce disparities in health care among enrollees in quality improvement programs. While CMS did not finalize a gold carding proposal, the Agency committed to considering a policy in future rulemaking.

Why it matters: The final rule streamlines coverage criteria used by MA plans, increases transparency of the prior authorization process and ensures continuity of care for patients. ASTRO will urge CMS to hold MA plans accountable for adhering to these new requirements and advocate against any new restrictions that impede timely access to care.

What’s next: CMS received comments on gold carding and left the door open for that to be included in future rulemaking. ASTRO eagerly awaits rule making on prior authorization burden reduction, including streamlining the process electronically and establishing PA determination timelines.