On January 25, 2024, the Centers for Medicare & Medicaid Services (CMS) issued a Request for Information regarding various aspects of the Medicare Advantage (MA) Program for the purpose of increasing transparency. CMS is soliciting comments on all aspects of data related to the MA program, with a particular interest in: data-related recommendations related to beneficiary access to care including provider directories and networks; and prior authorization and utilization management, including denials of care and beneficiary experience with appeals processes as well as use and reliance on algorithms. Comments must be received by May 29, 2024 as CMS is providing an extended comment period of 120 days to encourage feedback from a wider array of stakeholders and to allow time for convenings and other efforts to synthesize detailed feedback to CMS.
CMS’ RFI is part of the agency’s efforts to increase MA program transparency, including enactment of last month’s CMS Interoperability and Prior Authorization Final rule setting requirements for Medicare Advantage (MA) organizations, Medicaid and the Children’s Health Insurance Program (CHIP) fee-for-service (FFS) programs, Medicaid managed care plans, CHIP managed care entities, and ObamaCare plans to improve the electronic exchange of health information and prior authorization processes for medical items and services. This rule establishes requirements for certain payers to streamline the prior authorization process and complements the Medicare Advantage requirements finalized in the Contract Year (CY) 2024 MA and Part D final rule, which add continuity of care requirements and reduce disruptions for beneficiaries. Beginning primarily in 2026, impacted payers will be required to send prior authorization decisions within 72 hours for expedited (i.e., urgent) requests and seven calendar days for standard (i.e., non-urgent) requests for medical items and services. The rule also requires all impacted payers to include a specific reason for denying a prior authorization request, which will help facilitate resubmission of the request or an appeal when needed. Finally, impacted payers will be required to publicly report prior authorization metrics, similar to the metrics Medicare FFS already makes available.