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February 13, 2023

The Network Submits Comments to CMS on Prior Authorization Reforms

On February 13, 2023, The US Oncology Network submitted comments in response to the Medicare Advantage and Part D proposed rule for Contract Year 2024. The Network focused its comments on the proposals regarding utilization management. The Network applauded CMS for recognizing the barriers to timely access to care created by the increased use of prior authorization (PA) by Medicare Advantage (MA) plans and made several recommendations for further steps the agency could take to improve access for cancer patients.

Coverage Criteria for Basic Benefits
CMS proposed to codify standards for coverage criteria to ensure that basic benefits coverage for MA enrollees is no more restrictive than Traditional Medicare. Noting the proposal followed an April 2022 report released by the HHS Office of the Inspector General that found MA plans sometimes delayed or denied prior authorization and payment requests even though they met Medicare coverage rules, The Network supported CMS’ proposal to inject much needed transparency and accountability into the use of PA in MA and the development of MA plans’ internal coverage criteria. However, CMS stated it was not proposing to change the current authority for MA plans to use step therapy policies for Part B drugs. The Network strongly encouraged CMS to reconsider this position and reinstate the previous prohibition on step therapy for Part B drugs in MA plans.

Continuity of Care
CMS proposed to require MA plans to make all approved prior authorizations valid for the duration of the
entire approved prescribed or ordered course of treatment or service. The Network applauded this proposal and encouraged CMS to finalize it. The Network also supported the proposed requirement for plans to have a transition period for patients who switch to a new MA plan but cautioned that the 90-day period is insufficient for patients with treatment plans that extend beyond 90 days (such as metastatic patients or patients with breast cancer receiving adjuvant therapy).

Annual Review of Utilization Management Tools
CMS proposed to require MA organizations establish a Utilization Management (UM) committee to review UM policies annually and keep current LCDs, NCDs, and other Traditional Medicare coverage policies. CMS sought feedback on the composition and background of UM committee members and The Network encouraged CMS to required UM committee members be comprised of board-certified physicians in the applicable specialty.

Gold Carding
The Network also appreciated CMS’ recognition that of Gold Carding programs and encouraged MA plans to implement them.

To read The Network’s comments in full, CLICK HERE.