On April 5^th, the Centers for Medicare & Medicaid Services released a final rule outlining programmatic changes to Medicare Advantage (MA), Part D, Program for All-Inclusive Care for the Elderly (PACE) and the Medicare Cost Plan. The rule implements changes to prior authorization, health equity policies, coverage criteria, and network adequacy, among others. Stakeholders are pleased to see the changes that have been finalized and view them as a crucial step in providing timely and appropriate care to America’s seniors. The AUA signed a comprehensive comment letter prepared by the American Medical Association which addressed the provisions of the rule.

The rule finalizes policies that will align MA coverage guidelines with those of traditional fee-for-service Medicare. As such, MA plans will not be able to have separate or different coverage guidelines from traditional Medicare going forward and must adhere to national coverage determinations, local coverage determinations, and general coverage and benefits of traditional Medicare. Prior to this final rule, MA plans were able to create their own coverage determinations, creating unequitable care and coverage between MA and traditional Medicare.

The final rule also creates policies to create continuity of care and streamlines the prior authorization process by requiring a minimum of a 90-day transition period when a beneficiary enrolls or switches plans, meaning that the new plan may not request or require a new prior authorization for a course of treatment already in progress. In addition to this policy CMS also defined a course of treatment as it pertains to an approved PA request, as follows, an approved PA request “must be valid for as long as medically reasonable and necessary to avoid disruptions in care in accordance with applicable coverage criteria, the patient’s medical history, and the treating provider’s recommendation.”

Finally, MA plans will be required to establish utilization management committees to ensure that their plans are following the new policies and that the coverage and clinical criteria used to make PA decisions are adhering to traditional Medicare guidelines and coverage.

In addition to supporting the sign-on letter with the AMA, the AUA and the AMA joined a CMS roundtable on prior authorization with stakeholders from over 100 medical societies to support meaningful prior authorization reforms proposed for Medicare Advantage and the Medicare prescription drug benefit. Dr. Eugene Rhee, the AUA’s Public Policy Council Chair, met with CMS Administrator Chiquita Brooks-LaSure and the U.S. Surgeon General Vice Admiral Vivek H. Murthy, MD, to speak about the barriers that prior authorization poses to patient care and how ongoing communication is critical to ensuring CMS understands and addresses challenges physicians and patients face.

The AUA has been a long-time supporter of prior authorization reforms and also submitted a comment letter to CMS in support of the Advancing Interoperability and Improving Prior Authorization Proposed Rule. The proposing rule aims to reduce provider burden, increase transparency, and improve care coordination which results in higher quality patient care. Improving prior authorization policies can facilitate better coordination of care for the management of urological conditions.