CMS proposes health equity mandates for Medicare Advantage prior authorizations

CMS is proposing new health equity changes for prior authorization policies and procedures at Medicare Advantage organizations to better determine any disproportionate impact on underserved populations that may delay or deny access to services. 

"The goal of the health equity analysis is to create additional transparency and identify disproportionate impacts of utilization management policies and procedures on enrollees who receive the Part D low-income subsidy, are dually eligible, or have a disability," the agency wrote Nov. 6.

The health equity changes would be effective in contract year 2025 and are part of a broader proposed rule from CMS. Comments on the proposal are due by Jan. 5, 2024.

Three key proposals:

1. Medicare Advantage payers would be required to add a health equity expert to their utilization management committee.

2. The utilization management committee would have to conduct an annual health equity analysis of the insurers' Medicare Advantage prior authorization policies and procedures. The analysis would examine the impact of prior authorization on enrollees with one or more of the following risk factors: eligibility for Part D low-income subsidies, dual eligibility for Medicare and Medicaid, or having a disability — compared to enrollees without those risk factors. 

3. Payers would be required to publish the results of the analysis on their website. 

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