The ALS Association recently submitted a series of regulatory filings to reduce administrative burdens placed on people living with ALS.

The filings are in support of administrative rule changes at the Centers for Medicare and Medicaid Services that would reduce some administrative delays by improving prior authorization claims processes, instituting how and when Medicare Advantage plans develop and use coverage criteria and utilization management policies, and ensure that Medicare Advantage coverage policies are equivalent to traditional Medicare coverage.

ALS Association Prior Authorization Recommendations 

Prior authorization can be used by insurers to delay or deny coverage for treatments, forcing health care providers to seek permission in advance by submitting detailed information justifying the treatment and requesting insurance coverage. The ALS Association has prioritized public policies that curb the use of burdensome prior authorization and other utilization techniques to ensure that people living with ALS have access to effective treatments and quality health care services.

The Association believes two proposed rules move in the right direction on controlling misuse of these administrative burdens for people living with ALS.

Advancing Interoperability and Improving Prior Authorization Processes for Medicare Advantage Organizations (MA)

The ALS Association submitted comments to the Centers for Medicare & Medicaid (CMS) services on a proposed rule to help advance interoperability and improve prior authorization claims processes in Medicare Advantage. We strongly supported provisions of the proposed rule that would improve prior authorization processes to ensure timely access to needed items and services for patients and reduce burden on providers. 

We offer detailed comments on the provisions of the proposed rule: 

• We are supportive of CMS’s proposed requirements to implement standards for processing Medicare claims electronically through a Patient Access API. 
• We are supportive of CMS’s efforts to promote transparency and timely access to claims information for patients. 
• We encourage CMS to include drugs on its list of items and services subject to the proposed API requirements. 
• We recommend CMS consider a shorter deadline of 24 hours for expedited prior authorization requests. 
• We ask CMS to remind developers that the API is subject to federal nondiscrimination requirements. 

While we strongly support these proposals, we believe that CMS could take additional actions to ensure clear communication and understanding between plans and enrollees, and better protect patients against processing delays and ambiguous reasons for denials. 

Contract Year 2024 Policy and Technical Changes to the Medicare Advantage and Medicare Prescription Drug Benefit Programs

We strongly support CMS’s proposals to clarify and revise the regulations governing when and how Medicare Advantage (MA) plans develop and use coverage criteria and utilization management policies. We agree with CMS that the proposed policies would better protect MA enrollees and help ensure that they receive the same access to medically necessary care they would receive in Traditional Medicare.  

We offer detailed comments on the provisions of the proposed rule: 

• We support CMS’s proposals on prior authorization policies in the following: 
• For coordinated care plans that may only be used to confirm the presence of diagnoses or other medical criteria and/or ensure that an item or service is medically necessary based on standards specified by CMS;  
• Plans cannot deny coverage of a Medicare covered item or service based on internal, proprietary, or external clinical criteria not found in Traditional Medicare coverage policies; and  
• When there are no applicable coverage criteria, MA organizations may create internal coverage criteria that are based on current evidence that is made publicly available. 
• We support CMS’s proposal that MA plans must comply with national coverage determinations (NCD), local coverage determinations (LCD), and general coverage and benefit conditions included in Traditional Medicare statutes and regulations.  
• However, it is important that CMS’s NCDs and LCD policies are not overly restrictive or discounts the value of life of disabled or terminally ill individuals.  
• We are supportive of CMS’s proposal to require that all MA plans establish a Utilization Management (UM) Committee to review all utilization management policies annually to ensure they are consistent with current, traditional Medicare coverage guidelines. 
• We ask CMS to establish a process by which providers, clinicians, beneficiary advocacy groups, and others can provide feedback to CMS about the UM policies and practices used by MA plans.