When deciding whether to use Original Medicare with a Supplement Plan as primary coverage versus enrolling in an Advantage Plan, the growing concern many have is with Prior Authorizations. There has been a lot of chatter and negative attention in the media about Medicare beneficiaries being denied medical care by insurance companies. So, is this true? Should you be concerned? I think it is helpful to first understand what a Prior Authorization is for and how it came about. Then, I’ll share how to navigate that process to get what you need out of your plan. Let’s go…..
Prior Authorization Defined
The Center for Medicare and Medicaid Services or ‘CMS’ defines Prior Authorization as a request for provisional affirmation of coverage through review of the documentation that supports medical necessity. Notice that I said CMS defines…meaning Medicare defined it and created it. This is not a process created by the insurance companies to save money and deny care. This process was designed by Medicare to ensure that beneficiaries have access to necessary medical care while also combating fraud, waste and abuse carried out by providers. There have been many instances over the years of doctors, hospitals, ambulatory surgery centers, medical equipment providers, nursing home providers, etc. taking advantage of Medicare dollars and billing for services or equipment that were either unnecessary or did not even occur. And with the Medicare dollars running thin, CMS had to put something in place to put some parameters and controls on the overuse of Medicare dollars. This is to protect this fund and keep it going.
When Will I Need a Prior Authorization?
Technically any non-urgent medical service or equipment requires a Prior Authorization. Examples include elective surgeries like a knee, hip, shoulder, back, cataracts, tumor removal, etc., medical equipment, physical, occupational and speech therapy, inpatient stay at a rehabilitation center or nursing home and imaging (MRI, CT Scan) if non-urgent. In addition, many high cost brand name medications and narcotics require Prior Authorization. The provider, their office staff or third-party contractor submits the request to either Medicare or the insurance company if you are on an Advantage Plan. The request for Prior Authorization must include supporting documentation of medical necessity. The current standard turnaround timeline is 14 calendar days; however, new legislation is in process to shorten that to 7 calendar days which is slated to take effect in 2026. Once your service, medication or equipment has been approved, the provider may proceed.
Advantage Plans vs Original Medicare
This is where the controversy seems to come in and is being highlighted in the media and on social media. If you have Original Medicare, the provider should submit the documentation and Prior Auth request to CMS. However, this is rarely required or enforced. On the other hand, if you are on an Advantage Plan, the insurance carrier is the driver. They have much more sophisticated systems and teams of people handling Prior Authorizations in real time. They are more likely to hold providers to that medical necessity set forth by Medicare! This does sometimes lead to delays in approvals or denials altogether. However, often times, the failure to obtain approval lies with the provider office or third-party entity supplying the supporting documentation. They are sometimes late, or the documentation is not sufficient to prove medical necessity. This can be frustrating when you are having back pain or need your first refill of that brand name medication in the New Year. But remember why this process exists. If it is necessary, it will get approved! Be sure to check in with your provider’s office and watch the mail for communication from the insurance company.
New Year, New Plan, New Prior Auth
A very common issue that occurs at the beginning of each new year is related to a change in your plan. During that annual Medicare Open Enrollment season, many change either their stand-alone prescription drug plan or their Advantage Plan. Every time you change your plan, your brand name medication or ongoing therapy or treatments will require a new Prior Authorization from the new plan. One of the misconceptions when you change plans is suddenly it seems your new plan doesn’t cover your medication or treatment. If you have met with an agent, and they are doing it right – they have checked that before changing your plan. If so, it doesn’t mean its not covered…it just needs a new Prior Authorization from your Doctor.
Should I Avoid Advantage Plans?
There are two points to consider here. One is that a stand alone drug plan that you have alongside your Supplement plan also requires Prior Authorizations for some brand name prescription medications. So, you may deal with Prior Auths on both sides of the fence. However, I am not advocating that Advantage Plans are the best option or perfect for everyone either. That is a very personal and individual decision. CDI carries Medigap/Supplement plans and offers those as well! The important thing (point two) is to always take information from media and social media with a grain of salt. Seek guidance from a reputable source. There are so many benefits to Advantage Plans that may outweigh the hassle of Prior Authorizations depending on your situation. Understanding the process helps!
CDI is here to help you through this entire maze and find the option that makes the most sense for your health situation. We can meet in person or virtually. Reach out if you would like more information. Email carrie@cdi-cares.com or check out www.cdi-cares.com for a contact page and other helpful blogs.
https://www.cms.gov/files/document/prior-authorization-and-pre-claim-review-program-statistics.pdf
