Important Issues

CMS's announcement yesterday of new reforms to the Medicare Advantage, Medicaid, and Affordable Care Act plans' prior authorization rules are a huge step in reducing physician paperwork burden. They also mirror legislation passed by DC and supported by MSDC last year.

Among other changes, the new rules would require coverage for urgent treatments within 72 hours and seven day for non-urgent treatments. Insurers will also need to publicize prior authorization denial rates and justifications for denials. Changes will mostly be in place by 2026. However, the changes do not apply to all drug prescriptions.

These reforms were similar to those included in then-B25-124, the Prior Authorization Reform Amendment Act. That legislation applied to the private insurance market and (as of February) implements shorter turnaround times, more insurer disclosures and reporting, and more protections for patients' treatments from process abuse. The DC law did require funding in the District budget to apply to Medicaid and Alliance programs, although it is unclear how the new CMS requirements change this calculus.

American Medical Association analysis of CMS regulation