Medicare plans would use doctors to decide care approvals

Medicare contractors and plans would use qualified doctors to decide advance approval requests and coverage denials on medical grounds. This would cover Medicare claims contractors, Medicare Advantage plans, and Medicare prescription drug plans. Reviewers would need an unrestricted state medical license and board certification or eligibility in the specialty that usually handles the condition or service. Medical denials include reducing or ending coverage because care is deemed unnecessary, experimental, or investigational. Medical denials would require clinical direction from a medical director licensed in that state. The requirements would apply to contracts applying on or after the date 90 days after enactment.

Medicare contractors and plans would base coverage restrictions on medical need or suitability and written medical review rules. This would cover Medicare claims contractors, Medicare Advantage plans, and Medicare prescription drug plans. If no independently developed evidence-based standard exists for a service, coverage could not be denied solely because the service fails to meet one. The requirements would apply to contracts applying on or after the date 90 days after enactment.

Medicare contractors and plans would get doctors’ input on advance approval rules and apply those rules consistently. This would cover Medicare claims contractors, Medicare Advantage plans, and Medicare prescription drug plans. Before adopting or substantially changing rules, they would obtain input from local practicing, board-certified doctors representing major specialties and seek input from doctors outside their staff. Rules would follow national and community care standards, allow justified individual exceptions, and receive review at least annually, with updates if needed. The requirements would apply to contracts applying on or after the date 90 days after enactment.

Medicare contractors and plans would post advance approval rules and decision statistics online and notify contracted providers before changing requirements. Medicare claims contractors, Medicare Advantage plans, and Medicare prescription drug plans would make these disclosures available to patients, providers, and the public. Public rules would include detailed medical review criteria in understandable language. Contracted providers would receive written notice at least 60 days before new or amended requirements take effect, and websites would reflect the changes. Approval and denial statistics would be readily accessible online. The requirements would apply to contracts applying on or after the date 90 days after enactment.