MA prior authorization waiver

As we announced in January, Point32Health waived prior authorizations from Jan. 9, 2024 until April 1, 2024 for admissions from acute care hospitals to Massachusetts sub-acute care facilities and rehabilitation facilities for all applicable* Harvard Pilgrim Health Care and Tufts Health Plan products (commercial, Medicare Advantage/Senior Products, and Public Plans lines of business). We are now extending this waiver to Aug. 1, 2024.

These temporary flexibilities come as a coordinated and immediate response to the severe capacity challenges currently facing the Massachusetts health care system. As a result of record hospital occupancy levels, significant workforce shortages, and an uptick in COVID-19 cases and other respiratory viruses, the temporary waiver of prior authorization requirements is intended to support timely patient transitions to the most appropriate care setting.

In alignment with terms outlined in the directive from the Massachusetts Executive Office of Health and Human Services (EOHHS) and guidance from the Massachusetts Association of Health Plans:

• The waiver does not apply to long-term or custodial admissions.
• Point32Health will be permitted to conduct retrospective and concurrent review during this time to determine appropriateness of level of care.
• Acute care hospitals and post-acute care facilities in Massachusetts will be expected to notify Point32Health about any inpatient admission for which post-acute care is anticipated within 24 hours of admission and to provide updates, at a minimum of every 5 days, to support discharge planning.

In addition, as detailed more extensively in the directive, nursing facilities are expected to extend their hours of admission — and hospitals are asked to take measures related to timely discharge planning and care coordination, as well as staffing for medical/surgical beds.

Point32Health appreciates our provider network’s understanding and support in addressing these challenges, and we will be sure to keep you abreast of any significant updates as they are issued.

*Please note that the prior authorization waiver does not apply for US Family Health Plan, a TRICARE Prime health plan for eligible military families for which Tufts Health Plan provides administrative services.