A new rule on Medicare Advantage prior authorization finalized by the Centers for Medicare & Medicaid Services Wednesday suggests good news for providers and Medicare recipients.
The updated regulations are the latest in a string of recent signals that CMS is taking long-term care leaders’ concerns about MA plans seriously, stakeholders said.
Under the new rule, plans will have three days to send prior authorization decisions for expedited requests and seven days for standard requests. This will cut decision times by as much as half, according to a report on the rule from the US Department of Health and Human Services.
Any denials of coverage also will need to include the reasoning behind the denial, CMS wrote in a fact sheet about the new regulations.
Lawmakers and providers alike have asked CMS to change MA rules throughout the past year in order to lessen the financial burden on long-term care providers and Medicare patients.
“Impacted payers must provide a specific reason for denied prior authorization decisions regardless of the method used to send the prior authorization request,” the fact sheet confirms. “This requirement is intended to both facilitate better communication and transparency between payers, providers, and patients, as well as improve providers’ ability to resubmit the prior authorization request, if necessary.”
Finally, impacted payers are required to publicly report prior authorization metrics on their websites — supplying more transparent access to information already provided by Medicare Federally-Facilitated Exchanges for consumers, according to HHS.
Plans have until Jan. 1, 2026, to comply with the new regulations and must begin reporting on metrics by the end of March 2026.
The final rule is intended to streamline and modernize Medicare Advantage decisions and reduce the “patient and provider burden,” according to HHS.
Sector leaders have feared that previous rule changes would be circumvented by MA plans, but CMS has signaled a willingness to crack down on any such evasion and ensure that enforcement is not delayed.
