CMS issues FAQ on health plan administrative flexibilities

In response to frequently asked questions, the Centers for Medicare & Medicaid Services yesterday encouraged health insurers to relax otherwise applicable utilization management processes, as permitted by state law, to ensure that staff at hospitals, clinics and pharmacies can focus their limited time and resources on care delivery, and patients can receive needed care without delay.

The agency also encouraged insurers to work with out-of-network providers to agree upon a rate to ensure that enrollees are not balance billed, noting that enrollees may not be able to access treatment by an in-network provider during the emergency, and to consider additional administrative flexibilities as the public health emergency continues.

With respect to formulary drugs prescribed for off-label use to treat COVID-19, CMS said insurers may wish to apply utilization management practices to prevent shortages and ensure access to all who may benefit. Issuers also should ensure that any changes to prior authorization and utilization management are clinically based and applied in a non-discriminatory manner, and remain compliant with applicable essential health benefit regulations, the agency said.