New Public Data on Medicare Advantage Prior Authorization Shows Need for More Clarity

In 2024, the Centers for Medicare & Medicaid Services (CMS) finalized a rule that improved transparency around prior authorization for Medicare Advantage (MA) plans, as well as managed care plans in other programs like Medicaid. Those changes took effect this year. Starting April 1, MA organizations have been required to publicly report and display specific data around prior authorization. While this is an important step in the right direction, additional reforms are needed to ensure these data are as useful as possible.

What’s Reported

MA organizations must display how often they use prior authorization, deny requests, and overturn on appeal, as well as their processing times for these requests. The reporting applies to both standard prior authorization requests and ones that are expedited because of an urgent situation.

The data do not include prior authorization practices around any Part B or Part D drugs.

However, the data are reported on a contract basis and by contract number, making it very difficult for enrollees to find what they are looking for; in our experience, most beneficiaries are not generally familiar with how to extrapolate plan-specific details from this information. And they are incomplete. For example, the data do not include prior authorization practices around any Part B or Part D drugs, leaving this important category without needed transparency.

Public Access to Data

The organizations must publish their data on their public-facing websites. For example, UnitedHealthcare has a dedicated page on MA prior authorization that links to a pdf with all of their MA contracts listed. Humana has a “Prior Authorization Metrics” page that lists each contract by number and links to individual contract pdfs.

Finding these pages largely requires people to know what they are looking for ahead of time.

But finding these pages largely requires people to know what they are looking for ahead of time. The United page is fairly easy; while the data are not linked directly from the main page, searching “prior authorization” gives results that include the MA prior authorization page.

But getting to Humana’s data is more difficult to navigate. Searching “prior authorization” or “prior authorization metrics” from the main page does not return the correct page in any results. A user has to travel to the Humana site for providers, then search for “prior authorization metrics” (including quotation marks) to get a direct result.

If the goal is to increase transparency for enrollees, tucking the information away behind complex searches is ineffective.

What’s Missing

While information about the number of prior authorization requests and rate of denials, appeals, and overturns is important, other vital details are missing. For example, are the denials clustered around certain services? Certain conditions? Certain populations? What are the reasons for the denials? Why do so few people appeal?

Potential and current enrollees are denied important information about the plans they are considering or have already chosen.

And because the data are reported at the contract level, multiple plans may be mixed in. This means that potential and current enrollees are denied important information about the plans they are considering or have already chosen.

The Drug Exclusion

Importantly, the reporting also does not apply to any drugs, an exclusion that we objected to in our comments on the 2024 rule. A new proposed rule from CMS fills in this gap for Medicare Part B drugs. Part D drugs—the vast majority of prescription drugs for people with Medicare—are not part of that proposed rule.

A Vital Step but More Clarity Needed

At Medicare Rights, we supported the 2024 rule as an important step to improve the amount of information people with Medicare, researchers, and the general public have about how MA plans do business. But as the above details show, more must be done to make the information truly transparent and accessible. We will continue to engage CMS and lawmakers on these important reforms.