CMS finalizes rule for health plan prior authorization in certain federal programs

The Centers for Medicare & Medicaid Services today issued a final rule that seeks to streamline prior authorization processes implemented by health plans serving the Medicaid, Children’s Health Insurance Program and federal Health Insurance Marketplace. Under the rule, these plans will be required to build and implement certain application programming interfaces that could allow providers to know in advance what documentation is needed for prior authorization requests, streamline the documentation process, and enable providers to send requests and receive responses electronically, including directly from electronic medical records or other practice management systems. Notably, Medicare Advantage plans are excluded from the rule. The AHA previously submitted comments on the proposed rule; AHA members next week will receive a detailed Special Bulletin with details on this new policy’s impact on hospitals and health systems.

MedPAC discusses payment models, telehealth, SNF value-based purchasing

The Medicare Payment Advisory Commission this week discussed topics ranging from alternative payment models to telehealth and the value-based purchasing program for skilled nursing facilities.

In a follow-up to prior conversations about the future of alternative payment models and the Center for Medicare and Medicaid Innovation, the commission discussed policy options for refining and improving CMMI’s portfolio of models. The options include implementing a smaller suite of coordinated models designed to support a clear set of strategic goals; developing second-generation models only when specified criteria demonstrating promise have been met; and reducing or eliminating changes to models’ features once they are in the field. Commissioners also discussed challenges with current models and designing future models, especially regarding how to balance value-based payment and fee-for-service payment. The panel expects to discuss a draft recommendation at its March meeting.

Commissioners also reviewed policy options for expanding telehealth in Medicare after the public health emergency. Proposals included covering certain telehealth services for all beneficiaries and beneficiaries at home, restoring cost-sharing requirements, covering audio-only services for established patients, paying lower rates for telehealth than in-person services, and paying less for audio-only than telehealth, and safeguards to prevent fraud and abuse. Commissioners disagreed on a number of issues and raised the need for data on telehealth quality, utilization and continuity of care; options to pilot-test expansion; the role of direct-to-consumer telehealth companies; and preventing discrimination against certain patients. The discussion will be reflected in the commission’s March report to Congress and continue at future meetings.  

In another session, the commission discussed replacing the current SNF Value-based Purchasing program with a new incentive program informed by more quality measures and stratifying performance based on indicators of social determinants of health. The program will likely be introduced for a vote on recommendations at the April meeting.

Commissioners also discussed two Medicare coverage and payment options for routine vaccinations: covering all appropriate preventive vaccines and their administration under Medicare Part B instead of Part D without cost-sharing; and modifying Medicare’s payment rate for Part B-covered preventive vaccines from 95% of average wholesale price to 103% of wholesale acquisition cost. The latter proposal would require manufacturers to report ASP data to the Centers for Medicare & Medicaid Services for analysis. Commission staff plan to draft coverage and payment recommendations for consideration in March.

Leave a Reply

Your email address will not be published. Required fields are marked *