Medicare Advantage Plans Increasingly Require Prior Authorization for Key Services

Washington D.C. – A significant ‍majority of Medicare Advantage (MA) enrollees will be in plans requiring prior authorization for various services in 2025,a practice that contrasts‍ sharply with traditional Medicare.⁢ This⁤ requirement, often ⁢applied to higher-cost medical services, impacts nearly⁣ all beneficiaries enrolled in MA plans.

Prior Authorization: A Growing Trend in Medicare Advantage

In 2025, an overwhelming 99% of Medicare Advantage enrollees will be in⁣ plans that mandate ⁣prior authorization⁣ for ⁢at least some ‍services. This⁤ represents ⁣a consistent trend ‍from the⁣ previous year, indicating a widespread adoption of this⁣ administrative process⁤ by private ⁤Medicare plans.

Prior ‍authorization is most commonly required for services that typically⁣ incur higher costs. Thes include:

Skilled Nursing Facility Stays: 99% of enrollees are in plans requiring prior authorization.
Part⁣ B drugs: 98% of enrollees face this⁢ requirement.
inpatient ⁢Hospital Stays: 96% ‍for acute care and 93% for psychiatric⁤ care.
Outpatient Psychiatric Services: 80% of enrollees.

In stark contrast, ⁣prior authorization is rarely requested for preventive services, affecting only 7% of enrollees. Additionally, many enrollees in plans offering extra benefits, such ⁣as comprehensive dental services, hearing, and eye exams, ⁢may also‍ need prior authorization‍ for these ‍supplemental offerings.

Traditional Medicare vs. Medicare ⁢Advantage: A Key Difference

Unlike Medicare Advantage ‍plans, traditional Medicare generally⁢ does not require beneficiaries to obtain prior authorization before receiving services. Moreover, traditional Medicare does not mandate step therapy for Part B ⁤drugs,⁢ a practice where patients ⁣must try a less expensive drug first before a more expensive one is covered.This difference in ⁢administrative requirements can significantly impact patient access and ‍care coordination.

Transparency Gaps in Prior Authorization⁤ Data

While Medicare Advantage insurers⁤ are now obligated to publish some data regarding⁤ the‍ timeliness and utilization of prior authorization, critical information remains unavailable.Currently, there is no comprehensive data on⁣ how ⁢prior authorization requests, denials, and subsequent appeals vary by the type ‍of service, the specific plan, or the characteristics of the enrollee. This ⁤lack of granular data, as CMS‍ does not currently collect or report it, hinders a full understanding of the impact of prior authorization on beneficiaries.

Methods of Analysis

This analysis is based on data sourced from the Centers for‍ Medicare & Medicaid Services (CMS)⁤ Medicare Advantage Enrollment, Benefit and Landscape files for the respective years.It is important ⁣to note that KFF’s methodology has evolved. Since 2022, ⁣KFF has specifically focused on Medicare Advantage ‍plans, excluding other private plans ⁣such as cost plans, Programs of All-Inclusive Care for the Elderly (PACE) plans, and Health Care Prepayment Plans (HCPPs).This exclusion is due to potential differences in enrollment requirements and payment structures compared to traditional Medicare Advantage plans. These methodological ‍adjustments are reflected in both current data and historical trends dating back to 2010.

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Nancy Ochieng, Meredith Freed, jeannie ⁣Fuglesten Biniek, and Tricia Neuman are with KFF. Anthony Damico ⁤is an independent consultant.*