By Ciannah Correa
On June 16, 2025, the Centers for Medicare & Medicaid Services (CMS) indicated it will not enforce previously finalized regulations related to utilization management (UM) and prior authorization (PA) oversight in Medicare Advantage (MA). Specifically, CMS will not enforce rules requiring MA plans to include health equity expertise in their UM committees, nor rules that would have required MA UM Committees to produce and make public plan-level reports that would identify disparities or inequities in how they were approving or denying care. These regulations aimed to increase transparency around MA plans’ differences in approving care by income, dual eligibility and disability status – they would not have examined racial disparities.
Why this is important?
This is now the second action taken by the Trump administration to move away from MA prior authorization and UM guardrails and oversight. The administration previously declined to finalize requirements for AI oversight, MA plan transparency on PA approval rules, and service-level PA reporting. The suspension of these specific rules further reduces PA/UM transparency, at a time when care denials are causing significant public concern. In this blog, we discuss what has changed, what requirements are still in force for Contract Year (CY) 2026, and what these changes mean for enrollee choice and MA plan oversight.
Utilization Management Committees rely on physicians to represent the interest of their patients
In April 2023, CMS required all MA plans to establish a UM Committee to ensure that PA program consistency with Traditional Medicare coverage requirements. CMS set requirements for the composition of these UM Committees. For example, they must include practicing physicians across a multitude of specialties, at least one who specializes in care for older adults and/or people with disabilities, and at least one independent practicing physician with no conflicts of interest relative to the MA organization. The required range in physician type and expertise was designed to ensure that patients across diagnosis type and age are represented when plans make prior authorization decisions. MA enrollees are not currently required to be included in MA plans’ UM program development process.
CMS suspends enforcement of a rule that required expertise in health equity on UM Committees
In the CY 2025 MA and Part D Final Rule, CMS added a requirement that at least one UM committee member have expertise in health equity. This was defined as a physician with experience conducting studies to identify disparities among different population groups or enacting systems change to achieve equitable and fair care delivery for all MA enrollees in the plan. This requirement was in response to data showing that beneficiaries with certain social risk factors, such as those who were dually eligible for Medicaid, were subject to higher care denials in MA – up to twice the denials received by non-dual enrollees despite, on average, having fewer prior authorization requests. Moreover, dually eligible individuals are more likely to live in poverty and have higher rates of disability than those who are in MA only. Thus, this rule aimed to mitigate such disparities before realizing negative health outcomes by requiring a physician with health equity expertise to advise within the UM Committee. The suspension therefore reduces one mechanism CMS had established to help MA plans assess disparities in their UM practices.
CMS also suspends enforcement of more detailed prior authorization reporting by MA plans
The CY 2025 final rule included a requirement that the above-mentioned UM Committees publish a health equity analysis showing rates of denials and approvals of care by population. These reports would have highlighted any differences in PA practices for select populations: those who are dually eligible, low-income enrollees (identified by their enrollment in the Part D Low Income Subsidy program), and those with disabilities. This requirement would have increased CMS and the public’s visibility into how UM policies are applied to all enrollees and specific populations.
Another requirement of this rule was that the reports would have been more detailed. For example, it would require a summary of PA denials and approvals for items and services broken out instead of aggregated by service category. In addition, this reporting would be at the plan-level, rather than the currently-required aggregated reporting at the contract level. This more granular reporting would have provided local, relevant data for enrollees – rather than contract-level reporting that aggregates metrics across sometimes hundreds of plans from across the country.
Finally, the rule would have required more detailed and stricter posting requirements, ensuring reports were easily accessible and free to view. With these rules no longer enforcing clear, accessible, and standardized reporting of plan-level PA metrics, the extent to which reporting is public is left to each plan’s interpretation. Medicare beneficiaries, agents, counselors and providers will not be able to easily evaluate plans by their demonstrated PA practices, and CMS loses a potential source of data for oversight of MA plan PA practices.
What’s Next?
Some PA transparency requirements are still in effect. Beginning in 2026, MA organizations must publish a list of all items and services that require PA, and eight distinct metrics regarding PA approval and denial rates, including PA decision turnaround times. The approval and denial metrics must be reported on aggregate for all items and services at the contract level, not at the individual plan level. These metrics will help illustrate overall PA performance patterns for the first time, but they won’t reveal local or population-level differences.
Congress is considering taking on these issues. Bipartisan actions to improve UM/PA oversight and transparency, such as the Improving Seniors Timely Access to Care Act have been introduced with the intent of codifying in statute some reporting requirements and even taking first steps towards monitoring artificial intelligence use in PA, among other actions. Additionally, some MA organizations have participated in a voluntary pledge to streamline prior authorization processes, but this pledge does not include plan-level nor population-based reporting.
While the suspension of these PA transparency reporting requirements reduces some administrative burden for MA plans, it also eliminates the first opportunity for CMS, the public and providers to evaluate how prior authorization practices may be different based on enrollee income, Medicaid eligibility and disability. To reiterate, the selected populations face higher health risks when care is denied. MA plans can still choose to examine their PA practices by population, but it is at their discretion and not required to be public, nor would it be required by any existing legislation.
The suspension of these rules eliminates a potential source of information beneficiaries could use to make an informed choice. Medicare beneficiaries currently have few reliable, plan-level sources of information when they are comparing plans during open enrollment. As a result, most consumers currently choose an MA plan based solely on the cost of premiums or supplemental benefits offered, not realizing that plans may differ in the actual care they approve. The suspended requirements maintain a key information gap by removing the reporting of plan-level PA metrics that would have allowed enrollees, their assisters, advocates, researchers, and CMS to compare how PA policies affect populations with specific social risk factors – information that could be particularly relevant for consumers who face greater health risks if denied care.
The contract-level PA reporting that is still required to begin in 2026 will offer some insight into overall PA performance. But without plan-level and population-specific data, the public and CMS will lack accurate information about where, and for whom, denials are concentrated.