■ The Centers for Medicare and Medicaid Services (CMS) received numerous inquiries from various stakeholders, including the American Academy of Ophthalmology (AAO), regarding the use of prior authorizations (PA) by Medicare Advantage (MA) plans, and its effect on beneficiary access to care. CMS addressed these concerns in its recently released final rule. First, the final rule requires that coordinated care plan PA policies 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. Second, this final rule requires coordinated care plans to provide a minimum 90-day transition period when an enrollee currently undergoing treatment switches to a new MA plan, during which the new MA plan may not require PA for the active course of treatment. Third, to ensure PAs are being used appropriately, CMS is requiring all MA plans establish a Utilization Management Committee to review policies annually and ensure consistency with traditional Medicare’s national and local coverage decisions and guidelines. Finally, to address concerns that the earlier proposed rule did not sufficiently define the expected duration of “course of treatment,” the final rule requires that approval of a PA request for a course of treatment must be valid for as long as it is medically reasonable and necessary to avoid disruptions in care in accordance with applicable coverage criteria, the patient’s medical history, and the treating provider’s recommendation.

The rule aims to streamline the electronic exchange of health care information so that the PA process will respond to requests more efficiently. The AAO supports the PA clarifications in the final rule.