If you need a medical procedure, you may have to hold off on treatment until you have received approval from your health insurance plan.
In many cases, Medicare Advantage and other plans have been denying their patients certain services despite doctors’ orders. (In one survey, medical practices reported that 97 percent of their patients faced such unnecessary delays or denials.) Starting in January 2026, this may no longer be the case once a new federal rule becomes effective.
Negative Impacts on Patient Health
Patients, not to mention many physicians, find this so-called prior authorization process frustrating and illogical. In some cases, doctors assert, it can prove downright dangerous.
Prior authorization requests for medical procedures as well as prescription medications can sometimes last weeks or even months. With a significant delay or denials, patients may not receive medically necessary care in a timely manner. In 2022, the American Medical Association reported that, according to more than a third of doctors, the prior authorization process resulted in their patients being hospitalized, becoming disabled, or even dying.
The Final Prior Authorization Rule
The Center for Medicare and Medicaid Services (CMS) finalized its rule regarding prior authorizations earlier this month. The rule, set to be published in February 2024, outlines new timetables and requirements under which health insurers must process prior authorization requests. Here are the highlights:
- Starting in January 2026, Medicare Advantage, Medicaid, and Affordable Care Act plans will have to provide patients with a decision on urgent medical procedure requests within three days.
- For standard (non-urgent) prior authorization requests, these government-sponsored health programs will have no more than seven calendar days to issue a decision. (In some situations, Medicare Advantage would be able to implement an extension of up to 14 days to process these requests.)
- By the end of March 2026, insurers will also have to make public specific data related to their prior authorization review processes, including how many of these requests they approved or denied.
- Beginning in January 2027, patients must have the option to access details about their prior authorization records in digital format in addition to hard copy via mail. These notifications will include what services the patient requested, the status of their request, any reasons behind a denial, as well as other information.
According to the CMS, these changes will improve and expedite patients’ access to the health care procedures they need. In streamlining these processes, the CMS also seeks to provide consumers with more transparency about different plans as well as the reasons behind any denials. It estimates that the cumulative savings over the next decade as a result of the new rule will total $15 billion.
“Too many Americans are left in limbo, waiting for approval from their insurance company,” Xavier Becerra, U.S. secretary of Health and Human Services, said in a news release. “When a doctor says a patient needs a procedure, it is essential that it happens in a timely manner.”
Work With the Experts
For more information about Medicare and Medicaid plans, be sure to reach out to a professional.
An insurance agent can walk you through the different health plan options for which you may qualify. Similarly, an elder law attorney can offer you guidance on various health care plans and long-term care options. They also can assist you in appealing any denials of coverage. Find a qualified elder law attorney near you today.