April 22, 2020

CMS Urges Medicare Advantage Plans to Waive Prior Authorization

Following strong urging from the American College of Radiology® (ACR®) and other stakeholders, the Centers for Medicare and Medicaid Services (CMS) is now encouraging Medicare Advantage (MA) and Part D plans to waive prior authorization during the COVID-19 pandemic.

CMS continues to provide flexibility to plans to enable the best health care coverage in the current environment. It is working to address feedback received from stakeholders on prior authorization, risk adjustment and disruption to data collection.

In an April 21 guidance, CMS specifically states: “… consistent with flexibilities available to Medicare Advantage Organizations absent a disaster, declaration of a state of emergency, or public health emergency, Medicare Advantage Organizations may choose to waive or relax plan prior authorization requirements at any time in order to facilitate access to services with less burden on beneficiaries, plans and providers. Any such relaxation or waiver must be uniformly provided to similarly situated enrollees who are affected by the disaster or emergency. We encourage plans to consider utilizing this flexibility.”

ACR is also pressing CMS to recommend that MA and Part D plans waive prior authorization during the anticipated "post COVID-19 surge” of backlogged elective studies. Some of these studies may have received prior authorization before non-urgent care was shut down.

The ACR will continue to communicate and work with MA and Part D plans on this issue.