RISE summarizes recent regulatory-related headlines.
MA plans denied more prior authorization requests in 2022 than previous years
Medicare Advantage (MA) plans denied 3.4 million prior authorization requests for health care services in whole or in part in 2022, or 7.4 percent of the 46.2 million requests submitted on behalf of enrollees that year, according to a new KFF analysis of federal data.
Analysts said the figure represents a higher share of denials than in recent years. The share of all prior authorization requests denied by MA plans increased from 5.7 percent in 2019, 5.6 percent in 2020, and 5.8 percent in 2021.
The issue brief explores MA’s use of prior authorization, requests made in advance for higher cost services, such as inpatient hospital stays or chemotherapy, to manage utilization and lower costs. Researchers used data submitted by MA insurers to the Centers for Medicare & Medicaid Services to examine the number of prior authorization requests, denials, and appeals made in 2019-2022.
Among the key findings:
- More than 46 million prior authorization requests were submitted in 2022, up from 37 million in 2019.
- In 2022, insurers fully or partially denied 3.4 million (7.4 percent) prior authorization requests.
- One in 10 (9.9 percent) prior authorization requests that were denied were appealed in 2022.
- Eighty-three percent of appeals resulted in overturning the initial prior authorization denial.
Marketplace insurers propose a 7% average premium hike for 2025
KFF also reports that insurers in the Affordable Care Act (ACA) marketplace are proposing a median premium increase of seven percent for 2025, similar to the six percent premium increase filed for 2024. Analysts based the findings on preliminary rate filings but noted that the proposed rates may change during the review process.
In an announcement, KFF said that because most marketplace enrollees receive subsidies, they are not expected to face the added costs.
Drivers behind the rise in premiums include growing health care prices, particularly for hospital care and an increase in the use of weight loss and other specialty drugs, according to KFF’s examination of publicly-available documents. Insurers also cite premium increases on workforce shortages and hospital market consolidation.
The full analysis is available on the Peterson-KFF Health System Tracker, an online information hub dedicated to monitoring and assessing the performance of the U.S. health system.
CMS finalizes rule for breakthrough medical devices
The Centers for Medicare & Medicaid Services (CMS) this week issued a final rule for the Transitional Coverage for Emergency Technologies (TCET) pathway, providing device manufacturers with breakthrough or emerging technology with a faster way to secure Medicare coverage. The rule aims to help people with Medicare access the latest medical advances, enable doctors and other clinicians to provide the best care for their patients, and benefits manufacturers who create innovative technologies. The new TCET pathway increases the number of National coverage determinations that CMS will conduct per year and supports both improved patient care and innovation by providing a clear, transparent, and consistent coverage process while maintaining robust safeguards for the Medicare population. For more information, click here for the CMS fact sheet.