BMA Applauds CMS Prior Authorization Proposed Rule

Washington, D.C.  – Better Medicare Alliance, the nation’s leading research and advocacy organization supporting Medicare Advantage, responded today to the Centers for Medicare & Medicaid Services’ (CMS) proposed rule on prior authorization and interoperability.

“Better Medicare Alliance thanks CMS for their leadership in modernizing the prior authorization process for beneficiaries. While we continue to review the proposed rule in closer detail, we believe it complements our goals of protecting prior authorization’s essential function in coordinating safe, effective, high-value care while also building on the Medicare Advantage community’s work streamlining this clinical tool to better serve its 30 million diverse enrollees. We additionally welcome the proposed rule’s data exchange provisions, which will further improve communication between health plans, providers, and beneficiaries,” said Mary Beth Donahue, President and CEO of the Better Medicare Alliance. “Notably, the proposed rule addresses recent concerns from some lawmakers related to the budgetary impact of the BMA-endorsed Improving Seniors’ Timely Access to Care Act, legislation that already passed the U.S. House of Representatives with unanimous support.”

Background on Prior Authorization in Medicare Advantage:

• As findings published in JAMA explain, “the rationale for prior authorization is to identify and discourage costly low-value services, thereby reducing health care spending without impairing health care quality.”
• Separate research in JAMA demonstrates Medicare Advantage’s success in reducing low-value care: in a cross-sectional study of more than 2.4 million Medicare beneficiaries, those enrolled in Medicare Advantage received 9.2% fewer low-value services than those in FFS Medicare.
• A June 2021 poll of seniors on Medicare Advantage shows that less than half of seniors on Medicare Advantage say that they have ever encountered a prior authorization themselves and only 6% of seniors on Medicare Advantage say they have encountered prior authorizations “often.” Even among the minority of Medicare Advantage beneficiaries who have encountered prior authorizations, 66% say it imposes “no burden” on their health care experience.
• Similarly, a June 2022 survey of 2,800 Medicare Advantage beneficiaries conducted by eHealth showed that a combined 87% of respondents had not experienced a prior authorization denial or were unsure.
• Notably, findings published in JAMA in October 2022 report that “The use of prior authorization is also increasing in traditional Medicare.
• Better Medicare Alliance was a landmark supporter of the House-passed Improving Seniors’ Timely Access to Care Act and has continued to urge passage of bipartisan companion legislation in the Senate.

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