The Centers for Medicare & Medicaid Services (CMS) is proposing new limits on Medicare Advantage (MA) plans regarding prior authorization, utilization management, coverage decisions and the use of artificial intelligence (AI). These proposed changes aim to address the barriers to accessing care identified by CMS.

Data reported to CMS by MA plans show that, on average, these plans overturn 80% of their claim denial decisions when appealed. However, less than 4% of denied claims are actually appealed, indicating that many more denials could potentially be reversed through the appeals process. This data suggests that MA enrollees may not be receiving necessary care.

CMS is actively working to mitigate inappropriate prior authorization and other utilization management practices that limit access to care, create system-wide burden and negatively impact health care providers.

CMS’ utilization management audits, conducted throughout 2024 and into 2025, have informed the proposals outlined in this rule.

“We continue to hear from people enrolled in Medicare Advantage who are having difficulty accessing the care they need and are entitled to. CMS remains focused on removing these barriers,” Meena Seshamani, CMS deputy administrator and director of the Center for Medicare, said in a statement. “No senior or person with disabilities on Medicare should have to face challenges in navigating options, affording lifesaving medications prescribed by their doctor, or receiving the inpatient or rehabilitation care they need to recover.”

Some health plans have already begun to undo some burdensome prior authorization requirements.

In April, Point32Health, the parent company of Harvard Pilgrim Health Care and Tufts Health Plan, eliminated prior authorization requirements for the first 30 days of home health care for members in its commercial plans.

“We continuously evaluate our programs to ensure that our members receive the highest quality of care and work closely with our provider partners to reduce their administrative burden whenever possible,” Dr. Hermant Hora, senior medical director, said in a previous interview with Home Health Care News.

Traditional prior authorization has often posed challenges for providers. Lawmakers in Washington, D.C., have previously attempted to alleviate these issues with the Improving Seniors’ Timely Access to Care Act, passed by the House of Representatives in September 2022 and reintroduced by House and Senate leaders in June 2024. The act aims to enhance health care for seniors by reducing burdensome prior authorization processes. It requires MA plans to disclose their prior authorization rules, along with approval and denial rates.

“The prior authorization process should be based on the patient’s primary diagnosis and have a standard number of visit authorizations according to evidence-based medicine,” John Kunysz, CEO of Intrepid USA Healthcare Services, also previously told Home Health Care News. “Care delayed is care denied.”

The proposed rule for the Contract Year 2026 MA and Part D programs would also introduce stricter guidelines for using AI to safeguard access to health services.

On Oct. 30, 2023, the Biden-Harris Administration released an Executive Order on the Safe, Secure, and Trustworthy Development and Use of Artificial Intelligence. This order directs agencies to ensure that AI tools do not obstruct the advancement of equity and civil rights and that their use within health care organizations does not deny equal opportunity and justice to the American people.

Given the increasing use of AI in health care organizations, CMS asserts that it is essential to ensure that AI does not lead to inequitable treatment or bias within the health care system. Instead, AI should promote equitable access to care and person-centered care for all enrollees.

Additional policies include promoting competition regarding MA and Part D enrollees, further addressing misleading marketing practices and enhancing consumer tools on Medicare.gov.

“HHS is proposing to improve transparency, accountability and consumer protections in Medicare Advantage and Part D plans so that everyone receives high-quality care,” Xavier Becerra, Department of Health and Human Services secretary, said in a statement. “To achieve this, we aim to remove barriers that delay care or deny people the services and medications they need to maintain their health.”