Prior Authorization: Tougher Federal Rules Are a First Step to Protecting People with Medicare Advantage from Inappropriate Denials of Care

This blog is part of a series focusing on changes to Medicare’s private plan option (known as Medicare Advantage) aimed at strengthening the program to better serve the more than 32 million individuals enrolled in a Medicare Advantage plan today. A previous blog in this series focused on new Medicare Advantage marketing and sales rules.

Medicare Advantage (MA) plans – which now enroll about half of the nation’s Medicare population and are continuing to grow – commonly use certain insurance practices to help manage their enrollees’ health care use and contain costs. One such practice, known as prior authorization, requires enrollees to seek pre-approval through their health care provider before receiving certain health care services. The goal is to ensure that those services are appropriate and medically necessary.

While private health plans, including MA plans, commonly use prior authorization, mounting concerns over improper denials of care have led to increased congressional scrutiny and new federal guidelines for MA plans. Some of those rules took effect last month, while others apply starting in 2026. Although the new regulations are a positive development, continued vigilance and more oversight are necessary to ensure that the use of prior authorization does not result in improper coverage denials or delays in accessing needed care for people with MA.

A pervasive issue for people with Medicare Advantage

Unlike traditional Medicare (also known as Original Medicare) which generally does not use prior authorization, virtually all MA enrollees are in plans that require it for some services. Under prior authorization, if the insurer determines that the requested care is not medically necessary or is inappropriate, it can reject the request and deny coverage. MA plans differ in the specific services for which they require enrollees to seek prior authorization, but it is often needed for expensive services such as inpatient hospitalization, post-acute care in a skilled nursing facility, or chemotherapy infusions.

According to a recent study, MA insurers turn down millions of prior authorization requests each year. Although the vast majority of people faced with such a refusal do not appeal their plan’s decision, most of those who do appeal get their coverage denial overturned. This raises questions about the appropriateness of pre-authorization denials on a large scale. Indeed, other evidence suggests that inappropriate denials of pre-approvals for coverage are widespread in MA. More than one in ten such denials are for services that meet Medicare’s coverage rules and should be automatically covered by MA plans.

Potential harm to consumers

Inappropriate prior authorization denials can have serious health implications for MA enrollees, especially those with significant medical needs. By delaying or preventing access to medically necessary care, the often-lengthy pre-approval process can disrupt care delivery or lead people to abandon their treatment. It can also result in serious adverse events such as hospitalization or even death. In other cases, improper coverage denials create a significant financial barrier to accessing medical services ordered by a health care provider because, without insurance coverage, MA enrollees end up paying the full cost of their health care out of pocket.

For many people with MA and their caregivers, prior authorization also often creates a significant administrative burden as they work through the process with their clinician, and in some cases, through additional steps required to appeal an initial denial.

Finally, there is some evidence that problems getting health care services pre-approved may lead many MA enrollees to leave their plan. While often appropriate, changing MA plans can result in care disruptions, as moving to new health care coverage often involves switching providers and establishing new treatment strategies. And limitations on late Medigap enrollment could make it costly and difficult for these enrollees to switch to traditional Medicare.

Stricter prior authorization rules will help better protect Medicare Advantage enrollees

Under new federal guidelines effective since last month, the Centers for Medicare & Medicaid Services (CMS)—the federal agency that administers Medicare—clarifies that MA insurers may not use prior authorization to deny coverage for services that are included under traditional Medicare. In situations where Medicare’s rules are not fully spelled out, the new guidelines hold MA insurers to stricter requirements about when they can deny coverage through the prior authorization process.

In addition, to help protect against disruptions in care, the new CMS rules include more stringent requirements for how long MA plans’ prior authorizations must remain valid. Specifically, the guidelines require pre-approvals to stay in effect throughout a patient’s medical treatment. New plans must also honor existing prior authorizations for at least 90 days after an enrollee switches MA plans.

Finally, to safeguard against blanket denials (generated from, for example, software tools, predictive algorithms, or artificial intelligence), when examining pre-authorization requests, MA plans must consider each MA enrollee's specific health conditions and their treating clinician's recommendation.

CMS has also finalized other guidelines that take effect starting in 2026 and require MA plans to establish electronic prior authorization and shorten their pre-approval response times. To increase transparency, MA plans will need to provide timely status information on prior authorization requests in patient portals, as well as specific reasons for coverage denials. Finally, MA insurers will be required to publicly report summary prior authorization data on their website, including information on denial rates.

More consumer protections needed

Ensuring that prior authorization requirements do not create unnecessary barriers to needed care will require further change. To start, strong oversight and enforcement will be necessary to ensure MA plans comply with the new federal rules.

In addition, other areas where policy action could go a long way toward better protecting MA enrollees from problems with prior authorization include:

• ensuring that MA enrollees and their health care providers are aware of options to appeal a denial, processes to appeal prior authorization denials are easy to navigate, and consumers receive their appeal decision in a timely manner;
• encouraging appropriate reductions in the number of services requiring prior authorization in MA; and
• ensuring that prior authorization is not used in a manner that denies or delays access to services otherwise covered under traditional Medicare, especially for vulnerable MA enrollees.

With an ever-growing number of people choosing Medicare Advantage, the stakes are high when it comes to the rules of the road for prior authorization. It will become increasingly critical to ensure that improper uses of prior authorization requirements do not stand between MA enrollees and the care they need.