Prior authorization has long been part of the Medicare Advantage (MA) landscape, but over the past few years it has moved from a background administrative issue to a front-and-center policy debate – both inside Washington and well beyond it.
Providers, patient advocates, regulators, and lawmakers have all raised concerns about how prior authorization is used in Medicare Advantage plans, particularly around delays in care, administrative burden, and denials that are later overturned. At the same time, insurers argue that utilization management remains an important tool for controlling costs and ensuring appropriate care.
The result is an ongoing debate that agents selling Medicare products should understand.
Unlike Original Medicare (or Medicare + a supplement), Medicare Advantage plans commonly require prior authorization for a wide range of services, including hospital stays, skilled nursing facility care, advanced imaging, and certain outpatient procedures. According to the Kaiser Family Foundation (KFF), Medicare Advantage insurers process tens of millions of prior authorization requests in a single year, far more than traditional Medicare, where prior authorization is used sparingly.
Critics argue that while prior authorization is intended to prevent unnecessary care, it can also delay medically necessary services, add administrative costs for providers, and create confusion and frustration for beneficiaries, especially seniors who may not understand why approvals are required or how appeals work.
These concerns have been echoed by the Office of Inspector General, CMS, and members of Congress over multiple years.
The policy response has come in two main forms: regulatory changes and legislative proposals.
On the regulatory side, CMS has already taken steps to rein in certain practices. As explained by the Medicare Rights Center, recent CMS rules require Medicare Advantage plans to be more transparent about their prior authorization requirements, apply medical necessity criteria consistently, and improve timelines for decisions. CMS has also emphasized that plans must follow traditional Medicare coverage rules when determining whether services are medically necessary.
At the same time, CMS and HHS have publicly pressed insurers to streamline prior authorization processes, reduce delays, and expand electronic prior authorization systems to make approvals faster and more predictable.
While regulatory changes have helped at the margins, lawmakers from both parties argue that more structural reform is needed.
The most prominent legislative effort is the Improving Seniors’ Timely Access to Care Act, a bipartisan bill that has been reintroduced multiple times in Congress. The bill does not eliminate prior authorization in Medicare Advantage, but it would require plans to:
Supporters say these changes would reduce administrative burden and delays without removing utilization management entirely. The bill has broad bipartisan support, but, like many health policy measures, has not yet been enacted.
It’s important to note that this debate is not limited to Medicare Advantage. CMS has also explored prior authorization models within traditional Medicare through pilot programs, which has generated its own controversy and pushback from providers and lawmakers.
That broader context matters because it suggests something important: the policy conversation is not about whether prior authorization should exist, but how it should be used, and where guardrails should be placed.
For now, prior authorization remains a core feature of Medicare Advantage plans, even as the rules governing it continue to evolve.
For agents, this debate matters because it directly affects their clients. Prior authorization can influence 1) how quickly clients receive care, 2) how they perceive Medicare Advantage versus Original Medicare, and 3) whether they feel surprised or frustrated after enrolling
Agents don’t need to get into policy debates with clients, but understanding what’s changing – and what isn’t – helps set realistic expectations.
When prior authorization comes up with clients, a few practical things are worth keeping in mind:
For most clients, clarity matters more than policy details.
The debate over prior authorization in Medicare Advantage is ongoing, and meaningful changes are still being discussed, both through regulation and potential legislation. While nothing has eliminated prior authorization, the direction is clear: more transparency, faster decisions, and greater accountability.
Agents who understand this issue are better positioned to answer questions, manage expectations, and help clients choose coverage that makes sense for them.