Pallone Releases GAO Report on Medicaid Managed Care Plans’ Prior Authorization Requirements for Children

Energy and Commerce Committee Ranking Member Frank Pallone, Jr. (D-NJ) released a new report today, which he requested from the Government Accountability Office (GAO) on Medicaid managed care plans’ use of prior authorization for children’s health care benefits.

GAO looked into selected Medicaid managed care plans’ administration of the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit. The agency found inconsistencies among those plans’ prior authorization requirements for different children’s services and limited state oversight of prior authorization actions.

GAO made two recommendations to the Centers for Medicare & Medicaid Services (CMS) in the report: 1) communicate expectations to states on how to monitor the appropriateness of plans’ prior authorization decisions and confirm that states meet these expectations, and 2) clarify whether managed care plans can require prior authorization for EPSDT services when the state does not have such requirements.

“This report underscores the need for heightened oversight of Medicaid managed care plans’ use of prior authorization, especially when it comes to our children’s health care.” Pallone said. “These findings will inform Democrats’ ongoing investigation into the use of prior authorization and its impact on access to care.

“I also join GAO in recommending that CMS clearly define whether plans can require prior authorization for EPSDT services when the state Medicaid program does not have such requirements. I’m grateful to GAO for preparing this report, which will provide vital insight as Democrats continue to work with the Biden Administration to ensure our nation’s children have access to the care they need when they need it.”   

The full GAO report is available HERE.

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