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Does your Medicare Advantage plan require prior authorization?

Anyone who has compared Medicare Advantage plans knows that no two plans are alike. Different benefits, different costs, and different providers require you to pay close attention to the details. There’s another difference you might not have considered, that being prior authorization. 

Most plans may require prior approval of certain services. Some examples include inpatient admissions, skilled nursing facility stays, mental health services, home health care; chiropractic services, outpatient surgery and services, ambulance transport, medical equipment, diagnostic tests, and laboratory and radiology services.  

In the case of a procedure or test, the plan will either approve or deny the request. For services such as outpatient therapy or home healthcare, the plan will likely approve a certain number of visits. Getting more visits than that will require additional approval. 

It is the responsibility of the beneficiary to know the plan’s requirements and to ensure that services are authorized. Promotional information for plans likely will not mention this requirement. But, be aware. In 2020, 99% of all Medicare Advantage enrollees are in plans that require prior authorization for some services. 

How can a beneficiary find out about prior authorization requirements? Updates to the Medicare Plan Finder in late summer 2020 now identify "Limits apply" for all plans. Click on “Limits apply” next to each specific service or benefit to learn whether there is “advanced plan approval required." This could easily be 30 or more clicks on each plan.  

Three important notes about prior authorization:

  • One, beneficiaries with Original Medicare, with or without Medicare supplement insurance, generally do not face prior authorization requirements for doctors' visits, hospitalizations, diagnostic studies, or treatments. The Centers for Medicare and Medicaid Services (CMS) has two "prior authorization required" lists. One is for durable medical equipment, mostly power wheelchairs and mattresses, and the second is for outpatient services, such as eyelid surgery, excessive skin and fatty tissue excision, nose reshaping, and vein surgery. 
  • Two, without prior authorization, there either will be no service or the individual has to cover the full cost.
  • Three, both Medicare Advantage plans and stand-alone Part D prescription drug plans can require prior authorization of medications. The physician must contact the drug plan to get approval before writing the prescription. The plan wants to ensure that the drug is medically necessary and will be used appropriately. Also know that most Advantage plans require prior authorization of chemotherapy treatments. 

Dig into the details of your Medicare Advantage plan and make sure you understand the requirements. 

Last updated: 02-25-2021