Empowering Voters. Defending Democracy.

Prior Authorization in Medicare Advantage Plans

“While Medicare Advantage (MA) plans are required to cover the same health services as Original Medicare, they are not required to offer the same level of provider access and can impose coverage restrictions—like prior authorization—that require enrollees to take additional steps before accessing prescribed care. If a service is covered with prior authorization,” enrollees must get approval from the plan prior to receiving the service.

If approval is not granted or sought, the plan generally will not cover it.

A new analysis from the Kaiser Family Foundation looks at the prevalence of prior authorization in MA plans and found that many plans utilize this flexibility… Original Medicare, in contrast, does not require prior authorization for the vast majority of services, making this an important distinction between the two coverage options… MA’s broad application of prior authorization can impede access to care.

…While each MA plan has different rules…, many require enrollees to obtain approval before receiving an array of critical services… These requirements can often create barriers that may delay or prevent timely access to needed, affordable care.

Additionally, coverage denials can have significant financial implications for the enrollee. Many face high out-of-pocket costs as a result, in particular those who miss the short 60-day window of time to appeal. Unlike Original Medicare, MA enrollees must appeal within 60 days of the date of service. If they miss this deadline, they are held responsible for the charges.

…[In October] more than 100 lawmakers sent a letter to the Centers for Medicare & Medicaid Services (CMS) expressing concern about the use of prior authorization in MA plans, and asking for agency guidance to ensure that these requirements do not create inappropriate barriers to care for people with Medicare. (Lindsey Copeland, Medicare Rights Center)

About the author