Final 2025 MA Rule Includes More Prior Authorization Scrutiny

In a continued reexamination of prior authorization policies, the U.S. Centers for Medicare & Medicaid Services will require Medicare Advantage, or MA, plans to analyze the impact of prior authorization through a health equity lens.

New provisions of the final MA rule for 2025 expand on a 2024 rule that required MA plans to establish utilization management, or UM, committees to review prior authorization policies. Under the latest final rule, those committees must include an additional member with health equity expertise. That member will be responsible for approving a required report on the impact of a plan's prior authorization policies on enrollees who have social risk factors. MA plans will be required to make the analysis available to the public. Technically, the new provisions are effective June 3, 2024, but apply to coverage starting Jan. 1, 2025.

Generally, the analysis is required to use metrics including the percentage of approved and denied prior authorization requests, the percentage of successful appeals after denials, the percentage of extended but later-approved requests, and the average and median times elapsed between a prior authorization request and determination, among other data points. Those metrics will then be analyzed for any disproportionate impact on enrollees determined to be at social risk, defined as an individual who meets any of three criteria - having a disability, receiving a low-income subsidy, or being dually eligible for Medicare and Medicaid.

The analysis must be made available for free and posted prominently on the MA plan's website with no access requirements such as visitor information or passwords. The analysis also must be a machine-readable, digitally searchable file accessible from the footer link, and include a .txt file to enable access by researchers and third parties. The first analysis must be published by July 1, 2025.

CMS also requested public comment on diving even deeper into into prior authorization data in the future, a move that APTA supports. In earlier comments, APTA recommended that analyses look at prior authorization data related to individual therapy services provided by PTs, occupational therapists, and speech-language pathologists, given that these services are often tied with the disability social risk factor and subject to prior authorization at an extremely high rate.