Medicare Advantage Insurers Agree to Suspend Utilization/Medical Necessity Reviews

April 8, 2020

In response to GNYHA advocacy, the New York Health Plan Association (HPA) has advised that all of its members with Medicare Advantage (MA) products will voluntarily comply with Department of Financial Services (DFS) Circular Letter No. 8, which directs New York-regulated insurers to suspend a broad array of utilization and medical necessity reviews during the current COVID-19 emergency.

The chart below lists the MA plans that have agreed to comply with this directive.

Plan Applying Circular Letter No. 8 to Medicare Advantage
Aetna Yes
EmblemHealth Yes
Empire BCBS, HealthPlus Yes
Fidelis Yes
Healthfirst Yes
HealthNow Yes
Independent Health Yes
MetroPlus Yes
United Yes
WellCare Yes

The DFS directive requires insurers to suspend the following activities for at least 90 days from the date of the circular letter:

  • Preauthorization requirements for scheduled surgeries or admissions
  • Concurrent reviews of inpatient hospital services
  • Retrospective reviews for medical necessity of inpatient hospital and emergency services
  • Preauthorization requirements for inpatient rehabilitation services in a hospital or skilled nursing facility following a hospital admission
  • Preauthorization for home health care services following an inpatient admission
  • Notification requirements pertaining to inpatient admissions
  • Audits of hospital claims payments

We appreciate the responsiveness of these plans and HPA in working with GNYHA on this matter. We continue to work with them and with State regulatory agencies to ease additional insurer rules during the COVID-19 crisis.