capitol hill report: AAN RECOMMENDS MORE TRANSPARENCY IN MEDICARE ADVANTAGE

Building on a slate of recently finalized reforms impacting Medicare Advantage (MA), the AAN submitted a robust set of recommendations to the Centers for Medicare and Medicaid Services (CMS) in response to a request for information concerning the need for further transparency within the MA program.

The AAN’s recommendations include a call for the agency to expand on existing transparency requirements surrounding prior authorization and to require plans to disaggregate and publicly disclose relevant prior authorization data at the service level. The AAN also urged the agency to require additional transparency surrounding the use of artificial intelligence tools in the coverage determination process to ensure that care is not being inappropriately denied and that such tools do not exacerbate discrimination and bias.

Further, the AAN recommended that the agency reinstate the ban on step therapy for Part B drugs in MA, and absent such a decision, to release further data concerning the impact of step therapy policies on patient access to care.

Before the release of this critical request for information, CMS finalized two crucial rules that fundamentally reform how MA plans may implement utilization management policies including prior authorization.

The first rule was finalized in April 2023. Consistent with the AAN’s long-standing recommendations, it places crucial mandates on MA plans, most notably that beneficiaries must receive the same access to care as they would in traditional Medicare. Under this rule, MA prior authorization policies cannot be more restrictive than existing Medicare Fee for Service coverage policies. The rule also mandates that MA plans’ use of prior authorization may not function to delay or discourage clinically appropriate care and that MA plans must use widely accepted treatment guidelines and clinical literature when creating internal coverage criteria. Further, MA plans are also required to implement a 90-day authorization transition period when a patient transitions between payers into an MA plan during which an ongoing course of care cannot be subject to prior authorization. Lastly, denial reviews are required to be conducted by a professional with expertise in the relevant field of medicine.

The second rule, finalized in January 2024, was also consistent with AAN advocacy and recommendations. Applying to MA, Medicaid, and payers offering plans in the federally facilitated exchanges, it serves to develop the data sharing infrastructure needed to operationalize electronic prior authorization and requires the development of a standardized electronic prior authorization application. These requirements must be implemented by January 1, 2027. The rule also requires impacted payers to share specific reasons for denials and mandates that payers make decisions on prior authorization requests on a set timeframe—within seven calendar days for standard requests and within 72 hours for urgent ones. Further, this rule requires additional reporting of critical metrics that will allow patients, providers, researchers, and policymakers to better understand how plans are utilizing prior authorization. These operational or process-related policies were finalized with a compliance date starting January 1, 2026, and the initial set of metrics must be reported by March 31, 2026.

The AAN recognizes the specific impact that utilization management policies implemented by MA plans are having on beneficiary access to high-quality neurologic care. The AAN is committed to working with CMS to strengthen the MA program by ensuring that care is not inappropriately denied or delayed and that MA beneficiaries maintain robust access to neurologic care.