Staying Fit
Prior authorization is preapproval for medical services or prescription drugs that health insurance plans often require before they will cover the cost.
How often and under what circumstances prior authorization is required depends on the health plan. While Original Medicare has a few preapproval requirements, private Medicare Advantage plans and Part D prescription drug plans use this procedure more often.
AARP Membership— $12 for your first year when you sign up for Automatic Renewal
Get instant access to members-only products and hundreds of discounts, a free second membership, and a subscription to AARP the Magazine.
A provider or supplier typically must complete and submit forms to a health plan to verify the need for a specific drug, piece of equipment or service. Plans put these requirements in place to avoid paying for unnecessary services or expensive procedures and drugs when a lower-cost version that works just as well may be available. Patients also will know ahead of time if their plan will approve something that’s not always covered rather than having to appeal a denial afterward.
Prior authorization requirements vary by type of plan and insurer.
What is prior authorization in Original Medicare?
Original Medicare rarely requires prior authorization. The government program generally covers medically necessary services without requiring you or your doctor to submit special forms in advance or even a referral to see a specialist.
In the few instances when authorization is needed, a Medicare administrative contractor (MAC) reviews the request and makes a decision.
What is prior authorization in Medicare Advantage?
Prior authorization requirements are much more common in Medicare Advantage plans. A study from health researchers KFF, formerly the Kaiser Family Foundation, found that almost all Medicare Advantage enrollees in 2023 — 99 percent — are in plans that require prior authorization for some services.
Some of the most common services requiring prior authorization for Medicare Advantage plans include:
- Part B drugs: Medications generally taken in a doctor’s office, where 99 percent of enrollees are in Advantage plans that require preapproval
- Durable medical equipment: 99 percent
- Skilled nursing facility stays: 99 percent
- Sudden, short-term inpatient hospital stays, called acute care: 98 percent
- Psychiatric inpatient hospital stays: 93 percent
- Diagnostic lab work and tests: 92 percent
- Home health services: 91 percent
More on Medicare
Will Original Medicare Survive the Medicare Advantage Boom?
New enrollees increasingly opting for the private insurance alternative to the federally-run programThe Big Choice: Original Medicare vs. Medicare Advantage
Which path you take will determine how you get your medical care — and how much it costs
Medicare Open Enrollment: Everything You Need to Know
When it starts, when it ends, and how it works for original Medicare and Medicare Advantage
Recommended for You