Does Medicare Advantage require prior authorization, and for what services?
The short answer
Yes, most Medicare Advantage plans require prior authorization for many services. This means the plan must approve the care before you receive it, or the claim may be denied.
The full explanation
Prior authorization is a process where your insurance plan reviews and approves certain services before you get them. It is one of the most significant ways Medicare Advantage differs from Original Medicare, which requires prior authorization for very few services.The services that commonly require prior authorization in Medicare Advantage plans include inpatient hospital stays, skilled nursing facility care, certain specialty drugs, durable medical equipment like wheelchairs or CPAP machines, some imaging like MRIs and CT scans, home health care, and outpatient surgeries. The list is not the same across all plans. Each plan sets its own prior authorization requirements, and they can change from year to year.In practice, your doctor's office usually handles the authorization request on your behalf. But if authorization is denied, it can delay your care. You have the right to appeal a denial, and the plan is required to give you a written explanation.This is not a reason to avoid Medicare Advantage entirely, but it is worth understanding going in. If you have ongoing health conditions that require regular specialist visits, infusions, or specific equipment, ask any plan you are considering about its prior authorization requirements for those specific services. Surprises are harder to deal with when you are already unwell.Plans are required to follow CMS rules about authorization timelines and appeals, but the experience can still vary significantly by plan and situation.
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