AMRPA Access


CMS Issues Proposed Rule to Streamline Prior Authorization in Medicaid, CHIP and ACA Plans

By AMRPA Headquarters posted 12-16-2020 16:13



By Peter W. Thomas, JD, Principal, and
Joe Nahra, Director of Government Relations
Powers Law Firm

On December 10, the Centers for Medicare and Medicaid Services (CMS) issued a proposed rule titled, Reducing Provider and Patient Burden by Improving Prior Authorization Processes and Promoting Patients’ Electronic Access to Health Information. The rule would streamline prior authorization processes for Medicaid, Children’s Health Insurance Program (CHIP) and federal Affordable Care Act (ACA) plans, while also expanding on policies from CMS’ earlier Patient Access and Interoperability rule.

As proposed, the prior authorization provisions in this rule would not impact Medicare plans, including Medicare Advantage plans. As members may be aware, AMRPA has endorsed legislation in Congress, H.R. 3107, the Improving Seniors’ Timely Access to Care Act, that would streamline prior authorization and increase transparency for Medicare Advantage plans. This legislation continues to garner significant support in Congress, with more than 270 cosponsors in the House. The bill would:

  • Establish an electronic prior authorization process; minimize the use of prior authorization for routinely approved services;
  • Ensure prior authorization requests are reviewed by qualified medical personnel;
  • Require regular reports from Medicare Advantage plans on their use of prior authorization and rates of delay and denial; and
  • Prohibit the use of prior authorization for medically necessary services performed during pre-approved surgeries or other invasive procedures.

In fact, AMRPA is working to improve this legislation to more specifically address the needs of inpatient rehabilitation hospitals and units.

While the CMS proposal does not directly overlap with the provision in H.R. 3107, it does strive to accomplish many of the same goals. Among other policies, the rule would require impacted payers to include a specific reason for a denial when denying a prior authorization request, send prior authorization decisions within 72 hours for urgent requests and seven calendar days for standard requests, and publicly report data about their prior authorization processes, including the percentage of requests approved, denied, and ultimately approved after denial, and average time between submission and determination. If finalized, these policies would take effect January 1, 2023.

As noted above, these proposals would impact Medicaid and CHIP managed care plans, state Medicaid and CHIP fee-for-service programs, and Qualified Health Plan (QHP) issuers on the Federally facilitated Exchanges (FFEs). They would not impact traditional Medicare or Medicare Advantage plans, stand-alone dental plans, QHPs in the Small Business Health Options Program Exchanges (SHOPs), or QHPs provided through State-based Exchanges on the Federal Platform (SBE-FPs). However, CMS notes that future rulemaking could apply these policies to other payers not covered in this proposed rule.

The proposed rule also includes a number of Requests for Information (RFIs) seeking public feedback on the sharing of patient health information for future rulemaking. In particular, CMS seeks comment on:

  • reducing burden and improving electronic information exchange of documentation and prior authorization;
  • reducing the use of fax machines for health care data exchange;
  • accelerating the adoption of standards related to social risk data;
  • electronic exchange of behavioral health information; and
  • methods for enabling patients and providers to control sharing of health information.

The proposed rule is available to view here, and CMS’ press release is available here. Comments will be accepted through January 4, 2021.