Do Medicare Advantage Plans Require Prior Authorization?
September 17, 2024 | John Demko
Prior Authorization—whether you’re on Medicare or not, you’ve likely heard this term and may have some questions about it. This process, which is often necessary for certain medical services and medications, can seem daunting. Understanding the role of prior authorization in Medicare Advantage plans is an important part of making informed healthcare decisions. In this blog, we will cover what prior authorization entails, why it’s required, and how it specifically applies to Medicare Advantage plans, to help you navigate your healthcare choices with confidence.
What is a Prior Authorization?
Prior authorization is approval from a health plan that may be required before you get a service or fill a Part D prescription in order for the service or prescription to be covered by your plan.
Prior authorization can be required more commonly if the procedures, tests or prescriptions are considered costly or experimental. If the procedure is done without the approval of the plan – the plan may not pay for the procedure. Requirements vary between plans, so check with yours directly to avoid coverage or out-of-pocket surprises.
It’s important to note that traditional Medicare does still have prior authorizations based on medical necessity. Therefore, if you are under original Medicare and not part of a Medicare Advantage plan, prior authorizations will adhere to the regulations and criteria of original Medicare.
There are two main reasons why Medicare Advantage Plans use Prior Authorization:
- Control costs: plans can manage spending in hopes of maintaining lower premiums.
- Ensure medical necessity: This helps ensure that the services are medically necessary and appropriate for the patient.
Many times, prior authorizations happen without your knowledge. You may need a procedure or medication and your doctor has already filed for the prior authorization and your insurance has approved before you need the medication or before you can even get in for the procedure.
However, there is a growing concern among patients and providers. The process of prior authorizations, while serving a purpose, can also create unnecessary hurdles to essential care. This can be frustrating for both members and healthcare professionals, who often find themselves grappling with the administrative burden.
Future Prior Authorization Improvements
Fortunately, the Centers for Medicare and Medicaid Services (CMS) are actively working to address these concerns. Starting primarily in 2026, significant changes to the Prior Authorization process will be implemented. Urgent requests will need to be met within 72 hours, and standard requests within seven calendar days. This rule will also mandate all impacted payers to provide a specific reason for denying the request, ensuring transparency and accountability.
Learn More about the Improved Prior Authorization Process
Tips To Navigate the Prior Authorization Process
While dealing with prior authorizations can be challenging, here are a few tips that may help.
- Understand your plan’s coverage details: It’s important to have a clear understanding of what your insurance plan covers and what it doesn’t. If you have any questions about your coverage, don’t hesitate to reach out to our team for clarification.
- Communicate with your doctor: Open communication with your healthcare provider is key. Make sure to ask questions about the prior authorization process and discuss any concerns.
- Appeal denials: If a prior authorization request is denied, don’t hesitate to appeal the decision. Working with our team of insurance brokers can help you navigate this process.
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Do you need help with Medicare, insurance and health plans? Explore your options with Allina Health Aetna, BlueCross BlueShield of Minnesota, Medica, UCare, United HealthCare and more. We work with you to find the best plan for your needs and budget. Contact us today to get started.
