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January 22, 2024 at 03:42 PM
What You Need to Know
- Plans will have 72 hours to give providers reasons for denials for expedited coverage requests.
- Patients will see more information about preauthorization requests but will not be able to chime in.
- When a patient changes Medicare plans, the new plan will be able to pull five years of data from the old plan through an API.
New Medicare Advantage plan rules will give patients more information about plan coverage denials, but they won’t give the patients new tools that they and their brokers can use to lobby the plans directly.
Officials at the Centers for Medicare and Medicaid Services talk about the coverage tools patients will, and won’t, get in a new batch of final federal preauthorization and electronic health communication regulations.
The regulations will require affected plans to set up prior authorization “application programming interfaces,” or APIs, for communicating about preauthorization decisions with providers. Plans will have to get back to providers, and give reasons for any denials, within 72 hours for expedited requests, 7 calendar days for standard requests and 14 days if a patient, provider or plan asks for an extension.
Plans will have to feed preauthorization information into patients’ own health apps and plan portals through patient access APIs, but plans won’t have to give patients any new ability to participate in the preauthorization discussions. Agents or brokers who are authorized to act as the patients’ personal representatives could see the preauthorization information through their own portals or apps.
What it means: Medicare agents and brokers who help clients handle coverage problems might be able to get more information they can use to draft complaints and appeals.
But the new regulations won’t create any new systems or appeal programs that Medicare producers can use to speed up the decisionmaking.
The history: Health insurers and managed care providers argue that the preauthorization review is one of the few tools they have to reduce the cost of care and reduce the odds that patients will get unnecessary, potentially harmful or wasteful care.
Physicians have complained bitterly, for years, that plans tie them up with preauthorization reviews for ordinary, obviously needed care.
The mechanics: CMS, an arm of the U.S. Department of Health and Human Services, previously published major patient access API regulations in 2020.
The agency published a draft version of the new regulations in 2022 and received about 900 comments on the 2022 draft.
The regulation packet lists Natalie Albright as the CMS staffer who can answer questions about Medicare Advantage plan provisions and David Koppel as the staffer who knows about patient access API questions.
A preview version is already available on the web, but the official Federal Register publication date is expected to be Feb. 8.
The scope: The new regulations apply to Medicare Advantage plans and several other types of federally regulated private plans, including Medicaid managed care plans and the individual and family major medical policies sold through the Affordable Care Act public exchange system.
The regulations won’t apply to small-group ACA exchange plans, original Medicare coverage, stand-alone dental plans or Medicare supplement insurance policies,
Medicare Advantage plans provide coverage for 32 million of the 66 million people who are enrolled in Medicare.
The requirements: The new regulations set detailed standards for the technology behind the patient access API and the provider preauthorization access API, to ensure that patients and providers can see the data through as many different types of portals and apps as possible.
