RISE summarizes recent regulatory-related headlines.
Medical groups report an increase in MA prior authorization requirements
A recent survey of more than 600 medical groups by the Medical Group Management Association (MGMA) found that practices are experiencing additional prior authorization burdens as they see more Medicare Advantage (MA) patients. The survey found:
- 84 percent of the practices surveyed reported prior authorization requirements for MA have increased in the last 12 months, while less than one percent report that they had decreased
- 84 percent of practices report having to reauthorize existing Medicare-covered services for those Medicare beneficiaries who’ve switched plans
- 35 percent of medical groups report spending upwards of 35 minutes on an average single prior authorization request, with nearly five percent saying they spend 91 minutes or more
- 30 percent of medical groups report having to interface with 11 or more health plan proprietary web portals, with 76 percent of groups interfacing with five or more proprietary portals
- 60 percent of practices surveyed report that there are at least three different employees involved in completing a single prior authorization request
- 97 percent of medical groups report their patients experienced delays or denials for medically necessary care (e.g., prescription medicine, diagnostic tests, or medical services) due to prior authorization requirements
“With half of all Medicare beneficiaries enrolled in private Medicare Advantage (MA) plans, prior authorization reform has taken on new urgency at the federal level,” Anders Gilberg, senior vice president, government affairs, MGMA said in a statement. “Medical groups now identify prior authorization in the MA program as more burdensome than commercial insurance and Medicaid. More needs to be done to protect beneficiaries. MGMA supports commonsense policies that alleviate onerous administrative requirements and improve the timeliness of clinical care delivery.”
Sanders said the MGMA supports efforts to streamline, standardize, and reduce the volume of prior authorization demands on medical practices such as CMS’ proposed Prior Authorization and Interoperability Rule, and the Improving Seniors’ Timely Access to Care Act in Congress, to further strengthen and modernize the MA program.
KFF: Proposed work requirements could end Medicaid coverage for 1.7M people
A new KFF analysis finds that an estimated 1.7 million Medicaid enrollees could become ineligible for federal Medicaid under proposed work requirements and presents state-by-state projections, based on estimates of coverage loss from the Congressional Budget Office (CBO).
States could continue to provide Medicaid to those enrollees but would not receive federal matching funds for doing so. It is unclear if any states would choose to do that, though CBO estimated over half of enrollees would continue to be covered at the states’ expense. If states did choose to continue coverage, states could face up to $10.3 billion in additional costs in 2024, with five states in particular paying nearly half of the total:
- California (326,000, $1.6 billion)
- New York (186,000, $1.1 billion)
- Illinois (116,000, $692 million)
- Pennsylvania (83,000, $537 million)
- Washington (72,000, $578 million)
The CBO cost estimate included national estimates of coverage loss and changes in federal spending but did not include state-specific estimates or details about how individual states would respond or why. KFF estimates assume a 10 percent rate of Medicaid eligibility loss across all states, based on the national estimate released from the CBO; this rate could be higher or lower and not uniform across states.
The KFF analysis, similar to estimates issued by the Department of Health and Human Services, assumes that under the work requirements passed last month by the GOP-controlled House, all enrollees who become ineligible would be in Medicaid expansion states (40 states plus Washington D.C.). The new cost to the states equals 90 percent of total spending for affected enrollees—reflecting the 90 percent of costs that the federal government pays for expansion enrollees who would remain eligible for Medicaid only through state-funded coverage.
If the federal work requirements were applied more broadly across Medicaid eligibility groups, many more people could potentially be subject to reporting requirements, such as parents and people who cannot work due to a disability. Although most of those people likely would qualify for an exemption, some could lose Medicaid eligibility because they are unable to comply with reporting requirements.
While the mandatory work requirements were included in the debt ceiling legislation that passed the House of Representatives, the bill is not expected to pass in the Senate. It is unclear whether work requirements —or similar policies—could end up being debated as negotiations over the debt ceiling continue, or as part of broader federal spending and policy debates.
DEA to allow telehealth access for common medications despite the end of PHE
The Drug Enforcement Administration (DEA) said this week that it will temporarily extend the COVID-19 telemedicine flexibilities for prescription of controlled medications. The DEA received 38,000 comments on proposed rules released earlier this year that would limit prescriptions for buprenorphine and other controlled substances after the COVID-19 public health emergency ends on May 11. DEA Administrator Anne Milgram said the agency, in concert with the Department of Health and Human Services, has submitted a draft temporary rule to the Office of Management and Budget to temporarily extend the flexibilities. The draft is not yet publicly available, but details will be unveiled after its full publication in the Federal Register, Milgram said.