{"id":305123,"date":"2025-10-15T10:36:13","date_gmt":"2025-10-15T10:36:13","guid":{"rendered":"https:\/\/www.europesays.com\/us\/305123\/"},"modified":"2025-10-15T10:36:13","modified_gmt":"2025-10-15T10:36:13","slug":"does-medicare-require-prior-authorization","status":"publish","type":"post","link":"https:\/\/www.europesays.com\/us\/305123\/","title":{"rendered":"Does Medicare require prior authorization?"},"content":{"rendered":"<p><strong>Does Medicare require prior authorization?<\/strong><\/p>\n<p class=\"mb-4 text-lg md:leading-8 break-words\"><a href=\"https:\/\/www.goodrx.com\/insurance\/medicare\/medicare-advantage\" rel=\"nofollow noopener\" target=\"_blank\" data-ylk=\"slk:Medicare Advantage;elm:context_link;itc:0;sec:content-canvas\" class=\"link \">Medicare Advantage<\/a> plans often require <a href=\"https:\/\/www.goodrx.com\/insurance\/health-insurance\/prior-authorization-what-you-need-to-know\" rel=\"nofollow noopener\" target=\"_blank\" data-ylk=\"slk:prior authorization;elm:context_link;itc:0;sec:content-canvas\" class=\"link \">prior authorization<\/a>. But these coverage reviews are rare for original <a href=\"https:\/\/www.goodrx.com\/insurance\/medicare\" rel=\"nofollow noopener\" target=\"_blank\" data-ylk=\"slk:Medicare;elm:context_link;itc:0;sec:content-canvas\" class=\"link \">Medicare<\/a>. That distinction changes in 2026. Many older adults choose original Medicare (<a href=\"https:\/\/www.goodrx.com\/insurance\/medicare\/medicare-part-a\" rel=\"nofollow noopener\" target=\"_blank\" data-ylk=\"slk:Part A;elm:context_link;itc:0;sec:content-canvas\" class=\"link \">Part A<\/a> and <a href=\"https:\/\/www.goodrx.com\/insurance\/medicare\/what-is-medicare-part-b\" rel=\"nofollow noopener\" target=\"_blank\" data-ylk=\"slk:Part B;elm:context_link;itc:0;sec:content-canvas\" class=\"link \">Part B<\/a>) to avoid prior authorization. This step, which can delay and deny care, is common with private Medicare Advantage plans.<\/p>\n<p class=\"mb-4 text-lg md:leading-8 break-words\">Starting Jan. 1, 2026, a six-year pilot program in six states will use <a href=\"https:\/\/www.cms.gov\/newsroom\/press-releases\/cms-launches-new-model-target-wasteful-inappropriate-services-original-medicare\" rel=\"nofollow noopener\" target=\"_blank\" data-ylk=\"slk:prior authorization to review certain services and supplies;elm:context_link;itc:0;sec:content-canvas\" class=\"link \">prior authorization to review certain services and supplies<\/a> for original Medicare enrollees. This means that recommended care by a healthcare professional could be denied if you receive care in the targeted states. <a href=\"https:\/\/www.goodrx.com\/\" rel=\"nofollow noopener\" target=\"_blank\" data-ylk=\"slk:GoodRx,;elm:context_link;itc:0;sec:content-canvas\" class=\"link \">GoodRx, <\/a>a platform for medication savings, shares what this could mean for those who rely on Medicare.<\/p>\n<p class=\"mb-4 text-lg md:leading-8 break-words\"><strong>Key takeaways:<\/strong><\/p>\n<ul class=\"mb-4\">\n<li class=\"ml-4 list-disc\">\n<p class=\"mb-4 text-lg md:leading-8 break-words\">Original Medicare enrollees rarely face prior authorizations. They are far more common for people who have Medicare Advantage plans.<\/p>\n<\/li>\n<li class=\"ml-4 list-disc\">\n<p class=\"mb-4 text-lg md:leading-8 break-words\">In January 2026, a six-year pilot program of coverage reviews will begin for original Medicare enrollees. Prior authorization will be required for certain Medicare Part B services and items received in six states: Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington. The Part B services and items subject to these coverage denials have been deemed potentially wasteful and prone to fraud by the federal government.<\/p>\n<\/li>\n<li class=\"ml-4 list-disc\">\n<p class=\"mb-4 text-lg md:leading-8 break-words\">This pilot program does not apply to Medicare Part D prescription plans. Most of them already use prior authorization and step therapy. They also likely have quantity limits on some medications.<\/p>\n<\/li>\n<\/ul>\n<p>Does Medicare require prior authorization?<\/p>\n<p class=\"mb-4 text-lg md:leading-8 break-words\"><a href=\"https:\/\/medicareadvocacy.org\/prior-authorization\/\" rel=\"nofollow noopener\" target=\"_blank\" data-ylk=\"slk:Prior authorization;elm:context_link;itc:0;sec:content-canvas\" class=\"link \">Prior authorization<\/a> is preapproval of a service or medication by your health insurance plan.<\/p>\n<p class=\"mb-4 text-lg md:leading-8 break-words\">For years, Medicare Advantage and <a href=\"https:\/\/www.nytimes.com\/2025\/08\/28\/health\/medicare-prior-approval-health-care.html\" rel=\"nofollow noopener\" target=\"_blank\" data-ylk=\"slk:commercial insurance plans;elm:context_link;itc:0;sec:content-canvas\" class=\"link \">commercial insurance plans<\/a> have routinely required prior authorization for a broad range of healthcare. But <a href=\"https:\/\/www.axios.com\/2025\/06\/27\/medicare-add-prior-authorization-ai\" rel=\"nofollow noopener\" target=\"_blank\" data-ylk=\"slk:original Medicare;elm:context_link;itc:0;sec:content-canvas\" class=\"link \">original Medicare<\/a> has had few prior authorization requirements. In 2026, original Medicare will require prior authorization for certain services and items in six states.<\/p>\n<p class=\"mb-4 text-lg md:leading-8 break-words\"><a href=\"https:\/\/www.goodrx.com\/insurance\/medicare\/what-does-medicare-part-d-cover\" rel=\"nofollow noopener\" target=\"_blank\" data-ylk=\"slk:Medicare Part D;elm:context_link;itc:0;sec:content-canvas\" class=\"link \">Medicare Part D<\/a> prescription plans provide stand-alone drug coverage. They can also be part of a Medicare Advantage plan. Part D plans can <a href=\"https:\/\/www.medicare.gov\/health-drug-plans\/part-d\/what-drug-plans-cover\/plan-rules\" rel=\"nofollow noopener\" target=\"_blank\" data-ylk=\"slk:require prior authorization;elm:context_link;itc:0;sec:content-canvas\" class=\"link \">require prior authorization<\/a> as well as <a href=\"https:\/\/www.goodrx.com\/drugs\/savings\/what-is-step-therapy\" rel=\"nofollow noopener\" target=\"_blank\" data-ylk=\"slk:step therapy;elm:context_link;itc:0;sec:content-canvas\" class=\"link \">step therapy<\/a>. They may also impose quantity limits on covered medications.<\/p>\n<p class=\"mb-4 text-lg md:leading-8 break-words\">Prior authorization is also used to review whether <a href=\"https:\/\/www.goodrx.com\/insurance\/medicare\/dme-medicare-coverage\" rel=\"nofollow noopener\" target=\"_blank\" data-ylk=\"slk:durable medical equipment;elm:context_link;itc:0;sec:content-canvas\" class=\"link \">durable medical equipment<\/a> (DME), <a href=\"https:\/\/www.cms.gov\/data-research\/monitoring-programs\/medicare-fee-service-compliance-programs\/prior-authorization-and-pre-claim-review-initiatives\/prior-authorization-process-certain-durable-medical-equipment-prosthetics-orthotics-and-supplies\" rel=\"nofollow noopener\" target=\"_blank\" data-ylk=\"slk:prosthetics, orthotics, and other supplies;elm:context_link;itc:0;sec:content-canvas\" class=\"link \">prosthetics, orthotics, and other supplies<\/a> are necessary.<\/p>\n<p>Does original Medicare require prior authorization?<\/p>\n<p class=\"mb-4 text-lg md:leading-8 break-words\">Not usually. In most cases, <a href=\"https:\/\/www.medicare.gov\/publications\/10050-medicare-and-you.pdf\" rel=\"nofollow noopener\" target=\"_blank\" data-ylk=\"slk:you don\u2019t need advance approval;elm:context_link;itc:0;sec:content-canvas\" class=\"link \">you don\u2019t need advance approval<\/a> for a service or supply covered by original Medicare. That changes in 2026 for people who receive care in six states.<\/p>\n<p class=\"mb-4 text-lg md:leading-8 break-words\">A six-year <a href=\"https:\/\/www.cms.gov\/files\/document\/wiser-fact-sheet.pdf\" rel=\"nofollow noopener\" target=\"_blank\" data-ylk=\"slk:pilot program;elm:context_link;itc:0;sec:content-canvas\" class=\"link \">pilot program<\/a> will test prior authorization for certain Part B items and services. The reviews will be powered by <a href=\"https:\/\/www.nytimes.com\/2025\/08\/28\/health\/medicare-prior-approval-health-care.html\" rel=\"nofollow noopener\" target=\"_blank\" data-ylk=\"slk:artificial intelligence;elm:context_link;itc:0;sec:content-canvas\" class=\"link \">artificial intelligence<\/a> and machine learning.<\/p>\n<p class=\"mb-4 text-lg md:leading-8 break-words\"><a href=\"https:\/\/public-inspection.federalregister.gov\/2025-12195.pdf\" rel=\"nofollow noopener\" target=\"_blank\" data-ylk=\"slk:These services and items;elm:context_link;itc:0;sec:content-canvas\" class=\"link \">These services and items<\/a> may be subject to prior authorization:<\/p>\n<p class=\"mb-4 text-lg md:leading-8 break-words\">Prior authorization will not apply to inpatient services, emergency care, or care that would pose a substantial health risk if delayed.<\/p>\n<p class=\"mb-4 text-lg md:leading-8 break-words\">A healthcare professional can submit a prior authorization request before services are rendered. Or they can have a <a href=\"https:\/\/www.cms.gov\/data-research\/monitoring-programs\/medicare-fee-service-compliance-programs\/prior-authorization-and-pre-claim-review-initiatives\" rel=\"nofollow noopener\" target=\"_blank\" data-ylk=\"slk:prepayment medical review;elm:context_link;itc:0;sec:content-canvas\" class=\"link \">prepayment medical review<\/a> after services have been provided (though they risk not being paid). Companies hired to manage the program will be <a href=\"https:\/\/www.aamc.org\/advocacy-policy\/washington-highlights\/cmmi-releases-new-prior-authorization-model-medicare\" rel=\"nofollow noopener\" target=\"_blank\" data-ylk=\"slk:paid based on how much money they save the government;elm:context_link;itc:0;sec:content-canvas\" class=\"link \">paid based on how much money they save the government<\/a>. This is directly linked to how many claims for services are denied.<\/p>\n<p>Which states will be affected by the new original Medicare prior authorization pilot program in 2026?<\/p>\n<p class=\"mb-4 text-lg md:leading-8 break-words\">The <a href=\"https:\/\/www.cms.gov\/priorities\/innovation\/innovation-models\/wiser\" rel=\"nofollow noopener\" target=\"_blank\" data-ylk=\"slk:program;elm:context_link;itc:0;sec:content-canvas\" class=\"link \">program<\/a> will be deployed for care provided in six states:<\/p>\n<ul class=\"mb-4\">\n<li class=\"ml-4 list-disc\"\/>\n<li class=\"ml-4 list-disc\"\/>\n<li class=\"ml-4 list-disc\"\/>\n<li class=\"ml-4 list-disc\"\/>\n<li class=\"ml-4 list-disc\"\/>\n<li class=\"ml-4 list-disc\"\/><\/ul>\n<p>Do Medicare Advantage plans require prior authorization?<\/p>\n<p class=\"mb-4 text-lg md:leading-8 break-words\">Virtually every enrollee in a Medicare Advantage plan \u2014 <a href=\"https:\/\/www.kff.org\/medicare\/nearly-50-million-prior-authorization-requests-were-sent-to-medicare-advantage-insurers-in-2023\/\" rel=\"nofollow noopener\" target=\"_blank\" data-ylk=\"slk:99%;elm:context_link;itc:0;sec:content-canvas\" class=\"link \">99%<\/a> \u2014 is subject to prior authorization. Most often, it is for <a href=\"https:\/\/medicare.chir.georgetown.edu\/wp-content\/uploads\/Prior-authorization-fact-sheet-v2.pdf\" rel=\"nofollow noopener\" target=\"_blank\" data-ylk=\"slk:higher-cost services;elm:context_link;itc:0;sec:content-canvas\" class=\"link \">higher-cost services<\/a> such as:<\/p>\n<p class=\"mb-4 text-lg md:leading-8 break-words\">By November 2023, there were about 67 million people with Medicare. They were about equally split between original Medicare and <a href=\"https:\/\/www.goodrx.com\/insurance\/medicare\/medicare-advantage-cost\" rel=\"nofollow noopener\" target=\"_blank\" data-ylk=\"slk:Medicare Advantage plans;elm:context_link;itc:0;sec:content-canvas\" class=\"link \">Medicare Advantage plans<\/a>. That year, Medicare Advantage plans made <a href=\"https:\/\/www.kff.org\/medicare\/nearly-50-million-prior-authorization-requests-were-sent-to-medicare-advantage-insurers-in-2023\/\" rel=\"nofollow noopener\" target=\"_blank\" data-ylk=\"slk:nearly 50 million prior authorization decisions;elm:context_link;itc:0;sec:content-canvas\" class=\"link \">nearly 50 million prior authorization decisions<\/a> \u2014 on average, about two per enrollee. That\u2019s compared with about 400,000 prior authorization reviews for original Medicare enrollees in the same year.<\/p>\n<p class=\"mb-4 text-lg md:leading-8 break-words\">About 6.4% of the Medicare Advantage prior authorizations were denied in 2023. Yet most prior authorizations that were appealed \u2014 roughly 82% \u2014 were <a href=\"https:\/\/www.kff.org\/medicare\/nearly-50-million-prior-authorization-requests-were-sent-to-medicare-advantage-insurers-in-2023\/\" rel=\"nofollow noopener\" target=\"_blank\" data-ylk=\"slk:partially or fully overturned;elm:context_link;itc:0;sec:content-canvas\" class=\"link \">partially or fully overturned<\/a>.<\/p>\n<p>How does prior authorization work?<\/p>\n<p class=\"mb-4 text-lg md:leading-8 break-words\">Prior authorization means a healthcare professional must consult with your health plan about whether your care is medically necessary. Depending on your health plan\u2019s view of the care, your benefits can be approved or denied. The process of making a coverage decision can delay or prevent the care you need.<\/p>\n<p class=\"mb-4 text-lg md:leading-8 break-words\">The pilot program has been criticized as an experiment that will <a href=\"https:\/\/medicareadvocacy.org\/new-prior-auth-model\/\" rel=\"nofollow noopener\" target=\"_blank\" data-ylk=\"slk:complicate, deny, and delay needed care;elm:context_link;itc:0;sec:content-canvas\" class=\"link \">complicate, deny, and delay needed care<\/a>, while giving tech contractors performing the reviews financial incentives to deny claims. Critics say prior authorization, in general, <a href=\"https:\/\/time.com\/7313351\/medicare-prior-authorization-pilot-states-concerns\/\" rel=\"nofollow noopener\" target=\"_blank\" data-ylk=\"slk:prioritizes insurance company profits;elm:context_link;itc:0;sec:content-canvas\" class=\"link \">prioritizes insurance company profits<\/a> over patient care.<\/p>\n<p class=\"mb-4 text-lg md:leading-8 break-words\">For years, lawmakers and patient advocates have expressed concern about Medicare Advantage prior authorization reviews. A 2022 federal analysis concluded that Medicare Advantage <a href=\"https:\/\/oig.hhs.gov\/documents\/evaluation\/3150\/OEI-09-18-00260-Complete%20Report.pdf\" rel=\"nofollow noopener\" target=\"_blank\" data-ylk=\"slk:enrollees have been prevented from accessing medically necessary care;elm:context_link;itc:0;sec:content-canvas\" class=\"link \">enrollees have been prevented from accessing medically necessary care<\/a> and have faced denials at higher rates for certain services. These include <a href=\"https:\/\/www.hsgac.senate.gov\/wp-content\/uploads\/2024.10.17-PSI-Majority-Staff-Report-on-Medicare-Advantage.pdf\" rel=\"nofollow noopener\" target=\"_blank\" data-ylk=\"slk:rehab after hospital stays for strokes and falls;elm:context_link;itc:0;sec:content-canvas\" class=\"link \">rehab after hospital stays for strokes and falls<\/a>. An American Medical Association survey of physicians found that doctors view prior authorization as a <a href=\"https:\/\/www.ama-assn.org\/press-center\/ama-press-releases\/ama-survey-indicates-prior-authorization-wreaks-havoc-patient-care\" rel=\"nofollow noopener\" target=\"_blank\" data-ylk=\"slk:wasteful burden that disrupts care and increases healthcare costs;elm:context_link;itc:0;sec:content-canvas\" class=\"link \">wasteful burden that disrupts care and increases healthcare costs<\/a>.<\/p>\n<p>Can you appeal a prior authorization denial?<\/p>\n<p class=\"mb-4 text-lg md:leading-8 break-words\">If your Medicare or Medicare Advantage plan denies coverage for a service or an item, <a href=\"https:\/\/www.cms.gov\/priorities\/innovation\/files\/document\/wiser-model-frequently-asked-questions\" rel=\"nofollow noopener\" target=\"_blank\" data-ylk=\"slk:you can appeal;elm:context_link;itc:0;sec:content-canvas\" class=\"link \">you can appeal<\/a>. So can a healthcare professional or a supplier. This includes services that are not part of the pilot program. The <a href=\"https:\/\/www.goodrx.com\/insurance\/medicare\/appeal-a-medicare-payment-or-coverage-decision\" rel=\"nofollow noopener\" target=\"_blank\" data-ylk=\"slk:appeals process differs;elm:context_link;itc:0;sec:content-canvas\" class=\"link \">appeals process differs<\/a> depending on whether your coverage or payment denial comes from original Medicare or a Medicare Advantage plan.<\/p>\n<p>How do you know if your medication requires prior authorization?<\/p>\n<p class=\"mb-4 text-lg md:leading-8 break-words\">Your prescription plan\u2019s <a href=\"https:\/\/www.goodrx.com\/insurance\/health-insurance\/summary-of-benefits-and-coverage\" rel=\"nofollow noopener\" target=\"_blank\" data-ylk=\"slk:summary of benefits and coverage;elm:context_link;itc:0;sec:content-canvas\" class=\"link \">summary of benefits and coverage<\/a> can provide information about the medications that are likely to require <a href=\"https:\/\/www.goodrx.com\/insurance\/health-insurance\/prior-authorization-what-you-need-to-know\" rel=\"nofollow noopener\" target=\"_blank\" data-ylk=\"slk:prior authorization;elm:context_link;itc:0;sec:content-canvas\" class=\"link \">prior authorization<\/a>. When a medication requires prior authorization, a pharmacy typically notifies your prescriber to provide more information. You can also learn about a prior authorization from a pharmacy, but it\u2019s typically when your fill is delayed or denied.<\/p>\n<p>The bottom line<\/p>\n<p class=\"mb-4 text-lg md:leading-8 break-words\">For the most part, original Medicare enrollees have been able to avoid prior authorization. This ends for some in 2026. Starting Jan. 1, a six-year pilot program in six states will allow prior authorization reviews of certain services and items for original Medicare enrollees. According to the federal government, the test is intended to identify and prevent waste and fraud. Prior authorization contractors will use clinicians as well as technology to review claims and help the government avoid paying for items and services that have been flagged as potentially unnecessary treatment. You can appeal Medicare coverage denials. This includes those from a prior authorization review under the pilot program.<\/p>\n<p class=\"mb-4 text-lg md:leading-8 break-words\"><a href=\"https:\/\/www.goodrx.com\/insurance\/medicare\/does-medicare-require-prior-authorization\" rel=\"nofollow noopener\" target=\"_blank\" data-ylk=\"slk:This story;elm:context_link;itc:0;sec:content-canvas\" class=\"link \">This story<\/a> was produced by <a href=\"https:\/\/www.goodrx.com\/\" rel=\"nofollow noopener\" target=\"_blank\" data-ylk=\"slk:GoodRx;elm:context_link;itc:0;sec:content-canvas\" class=\"link \">GoodRx<\/a> and reviewed and distributed by <a href=\"https:\/\/hubs.la\/Q03klgSR0\" rel=\"nofollow noopener\" target=\"_blank\" data-ylk=\"slk:Stacker;elm:context_link;itc:0;sec:content-canvas\" class=\"link \">Stacker<\/a>.<\/p>\n","protected":false},"excerpt":{"rendered":"Does Medicare require prior authorization? Medicare Advantage plans often require prior authorization. But these coverage reviews are rare&hellip;\n","protected":false},"author":3,"featured_media":305124,"comment_status":"","ping_status":"","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[35],"tags":[210,1141,1142,3235,28533,91326,30919,67,132,68],"class_list":{"0":"post-305123","1":"post","2":"type-post","3":"status-publish","4":"format-standard","5":"has-post-thumbnail","7":"category-health-care","8":"tag-health","9":"tag-health-care","10":"tag-healthcare","11":"tag-medicare","12":"tag-medicare-advantage","13":"tag-pilot-program","14":"tag-prior-authorization","15":"tag-united-states","16":"tag-unitedstates","17":"tag-us"},"share_on_mastodon":{"url":"https:\/\/pubeurope.com\/@us\/115377745639556259","error":""},"_links":{"self":[{"href":"https:\/\/www.europesays.com\/us\/wp-json\/wp\/v2\/posts\/305123","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.europesays.com\/us\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.europesays.com\/us\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.europesays.com\/us\/wp-json\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/www.europesays.com\/us\/wp-json\/wp\/v2\/comments?post=305123"}],"version-history":[{"count":0,"href":"https:\/\/www.europesays.com\/us\/wp-json\/wp\/v2\/posts\/305123\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.europesays.com\/us\/wp-json\/wp\/v2\/media\/305124"}],"wp:attachment":[{"href":"https:\/\/www.europesays.com\/us\/wp-json\/wp\/v2\/media?parent=305123"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.europesays.com\/us\/wp-json\/wp\/v2\/categories?post=305123"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.europesays.com\/us\/wp-json\/wp\/v2\/tags?post=305123"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}