In the Medicare Contract Year 2025 proposed rule, the Centers for Medicare and Medicaid Services (CMS) builds upon the prior authorization requirements finalized in the 2024 final rule by proposing policies that require Medicare Advantage (MA) plans to improve transparency related to the effects of prior authorization on underserved communities.

CMS is concerned that prior authorization policies may disproportionately inhibit access to care for underserved enrollees. To provide additional safeguards, CMS is proposing to require that MA Utilization Management (UM) committees include a health equity expert and conduct an annual health equity analysis of the plans’ prior authorization policies and procedures. This analysis would examine the impact of prior authorization on enrollees with one or more of the following social risk factors:

• Eligibility for Part D low-income subsidies,
• Dual eligibility for Medicare and Medicaid, or
• Having a disability

CMS is also proposing to require MA plans to make the results of the analysis publicly available on plan websites to improve transparency related to the effects of prior authorization on underserved populations.

CMS welcomes comment on this proposal and is seeking comment on whether the health equity analysis should include specific analysis associated with the impact of prior authorization on members of racial and ethnic communities, members of the lesbian, gay, bisexual, transgender, and queer (LGBTQ+) community; individuals with limited English proficiency; members of rural communities; and persons otherwise adversely affected by persistent poverty or inequality.

● If there should be further definition for what constitutes “expertise in health equity,” and if so, what other qualifications to include in a definition of “expertise in health equity.”