CMS Prior Authorization Final Rule

04/22/24 • 2 min

Petauri PACT Executive Briefings - 3-Minute Market Insights

Today's topic is the CMS Prior Authorization Final Rule
On January 17th, 2024, CMS published the CMS Interoperability and Prior Authorization Final Rule, to improve the electronic exchange of health care data as well as to streamline prior authorization processes. This final rule also adds a new measure for merit-based incentive payment system or MIPS eligible clinicians.
Beginning in January 2026, health insurers participating in federal programs including Medicare advantage and Medicaid, must respond to expedited (that's "urgent") prior authorization requests within 72 hours and standard (or "non-urgent") requests within seven days. Insurers must also include their reasons for denying a prior authorization request and will be required to publicly release data on denial and approval rates for medical treatment.
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Federal No Surprises Act

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Today’s topic is the Federal No Surprises Act.

The Federal No Surprises Act is intended to protect consumers from unexpected medical bills that occur when a patient unknowingly receives medical services from physicians and other providers who are outside of their health insurance network; in other words, healthcare providers who are not “in network”.

The law protects consumers specifically from surprise medical bills in three main scenarios:

1. Emergency care from an Out-of-Network provider at an In-Network facility;

2. Any care from an undisclosed Out-of-Network provider; and

3. Uninsured or self-pay patients from unknown costs.
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State Drug Price Transparency Laws

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Since 2016, 13 states have passed Drug Price Transparency Laws focused on enabling state policymakers to understand opaque drug pricing and payment systems to formulate policy solutions to high prices, while also creating the data infrastructure to realize those policy solutions.

Most of these state programs require reporting from manufacturers when they increase the Wholesale Acquisition Cost (WAC) of a drug above a certain threshold or if they introduce a drug with a high launch price.

Since 2020, 8 states have enacted Prescription Drug Affordability Boards often referred to as P-DABs, entities with the authority to review high cost drugs and in some states set an upper payment limit to ensure no one pays more than that amount in the state.
You can download the full Executive Briefing at: https://tkgpact.com/executive-briefings/

Or, feel free to email us at [email protected]