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CMS Implements Groundbreaking Prior Authorization Reforms

In a monumental move, the Centers for Medicare and Medicaid Services (CMS) has unveiled a final rule that marks a decisive stance against hindering essential medical care through the misuse of prior authorization by health insurance providers.

Starting in 2026, the new rule mandates Medicare Advantage (MA) plans to respond to urgent prior authorization requests from doctors within a swift 72-hour window, while standard requests must be addressed within seven (7) days. This significant development will alleviate the burdensome delays that people living with ALS face in obtaining crucial care, including access to vital medical equipment and supportive services.

“Thank you to the many advocates who educated policy makers about this need for ALS patients,” said Tony Heyl, Director of Communications and Public Policy at ALS United Mid-Atlantic. “This is an important step towards ensuring that people with ALS receive the care they need with as few delays as possible.”

ALS United Mid-Atlantic serves over 1,200 people with ALS each year in Pennsylvania, New Jersey, and Delaware through comprehensive care programs and 8 respected multidisciplinary ALS Treatment Centers. Click here to learn more about our services for ALS families.

The new rule compels insurers to provide specific reasons for denials, facilitating smoother claim resubmissions and appeal processes. Insurers will also be mandated to publicly report prior authorization metrics and adopt an electronic prior authorization system, contributing to a more efficient healthcare ecosystem.

CMS anticipates that these policies will streamline prior authorization processes, reducing the burden on patients, providers, and payers, with an estimated savings of approximately $15 billion over the next ten years.

Visit these links to read more about this important rule change from CMS:

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