Prior authorization requirements are very common in Medicare Advantage plans. Almost all Medicare Advantage enrollees are in plans that require prior authorization for some services, the most common being:
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Durable medical equipment: 99 percent
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Skilled nursing facility stays: 99 percent
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Sudden, short-term inpatient hospital stays, called acute care: 98 percent
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Part B drugs, which are generally given in a doctor’s office or outpatient center, such as chemotherapy: 98 percent
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Psychiatric inpatient hospital stays: 93 percent
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Diagnostic lab work and tests: 92 percent
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Home health services: 90 percent
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Diabetic supplies and services: 87 percent
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Comprehensive dental services: 86 percent
Medicare Advantage plans are prohibited from applying prior authorization requirements on emergency services, and they must disclose rules and other review requirements to enrollees. Before choosing a Medicare Advantage plan, we review the plan’s evidence of coverage (EOC) with you so that you understand the plan’s its prior authorization rules.
Beginning in 2026, Medicare Advantage plans are subject to new prior authorization rules that shorten the time frame for insurers to respond to requests from 14 to 7 days and make the process more transparent.
