The Centers for Medicare and Medicaid Services final rule prevents health insurers from using delay tactics to deny care.

WASHINGTON, D.C. (January 17, 2024) – Today, the Centers for Medicare and Medicaid Services (CMS) issued a final rule that cracks down on the use of prior authorization by health insurance companies to delay approving necessary medical care. The new rule requires Medicare Advantage (MA) plans to respond to a doctor’s urgent prior authorization request within 72 hours and standard request within seven (7) days starting in 2026. The plan must also provide specific reasons for denials which will also help improve claim resubmission and appeal timeframes.

The ALS Association has been collaborating closely with officials in the Administration and at CMS on this rule and played a leading role in helping to craft this regulation. 

MA plans’ overuse of prior authorization has led to substantial administrative burdens for people living with ALS and their providers and caused significant delays in necessary care such as access to complex medical equipment and supportive services that make ALS a more livable disease.

“The ALS Association is grateful to everyone at CMS who worked tirelessly on these reforms,” said Melanie Lendnal, Senior Vice President of Policy and Advocacy at The ALS Association. “People living with ALS need and deserve prompt access to medically necessary services and equipment such as complex wheelchairs, ventilators, and speech generating devices. It is unacceptable for a person living with ALS to suffer needlessly while their physician appeals rejected claims to health insurers.” 

Under the new rule, insurers will also be required to publicly report prior authorization metrics and utilize an electronic prior authorization process to foster a more efficient health care system. 

CMS believes these policies will improve prior authorization processes and reduce burden on patients, providers, and payers, resulting in approximately $15 billion of estimated savings over ten years.

The final rule is available to review here: https://www.cms.gov/files/document/cms-0057-f.pdf - PDF.

The fact sheet for this final rule is available here: https://www.cms.gov/newsroom/fact-sheets/cms-interoperability-and-prior-authorization-final-rule-cms-0057-f.

ABOUT ALS
Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease that affects nerve cells in the brain and spinal cord. Over the course of the disease, people lose the ability to move, to speak, and eventually, to breathe. On average, it takes about a year before a final ALS diagnosis is made. The disease is always fatal, usually within five years of diagnosis. There is no cure. 

ABOUT THE ALS ASSOCIATION
The ALS Association is the largest philanthropic funder of ALS research in the world. The ALS Association funds global research collaborations, assists people with ALS and their families through its nationwide network of care and certified clinical care centers, and advocates for better public policies for people with ALS. The ALS Association is working to make ALS a livable disease while urgently searching for new treatments and a cure. For more information about the ALS Association, visit our website at www.als.org.