8 Services Medicare Advantage Won’t Cover Without Preapproval

Photo by Alexander Raths / Shutterstock.com

If you have Medicare — or are about to sign up for the government health insurance program — beware of making uninformed decisions. They could cost you.

Every new Medicare enrollee must choose between the two main types of Medicare plans — Original Medicare and Medicare Advantage. Existing enrollees also must weigh this choice during open enrollment.

The option you choose will determine whether or not you are subject to prior authorization requirements, which can result in your insurer refusing to pay for a health care service.

Original Medicare — also known as traditional Medicare — does not require prior authorization for the vast majority of services. By contrast, Medicare Advantage often does require such prior authorizations.

A recent analysis by the nonprofit Kaiser Family Foundation (KFF) found that 80 percent of folks with Medicare Advantage are enrolled in plans that require prior authorization for at least one Medicare-covered service.

What is prior authorization?

Prior authorization requires enrollees to get approval from the plan before accessing a particular health care service. If the plan does not approve the service beforehand, the plan might not pay for the service — leaving the patient on the hook for the cost.

Ideally, prior authorization deters unnecessary medical care and fraud. In reality, though, prior authorization can delay or prevent access to necessary medical care, according to both KFF and the nonprofit Medicare Rights Center.

According to the center, patients have 60 days to appeal if an insurer declines to cover a service. But if patients miss that deadline, they will be responsible for paying for the service out of pocket.

8 common prior authorization requirements

The KFF analysis found that Medicare Advantage plans frequently require enrollees to get prior authorization for several types of health care services , including the following eight:

  • Durable medical equipment: 73 percent of Medicare Advantage enrollees have plans that require prior authorization for this service.
  • Part B (doctor-administered) drugs: 71 percent
  • Skilled nursing facility stays: 71 percent
  • Inpatient hospital stays: 70 percent
  • Ambulance services: 62 percent
  • Home health services: 62 percent
  • Procedures, labs and tests: 61 percent
  • Mental health services: 57 percent

The analysis notes that Medicare Advantage plans typically use prior authorization for “relatively high-cost services used by enrollees with significant medical needs.” The first four services listed above are among the costliest.

What it means for you

This does not mean you should automatically choose Original Medicare over Medicare Advantage. While Medicare Advantage plans sometimes come with restrictions that traditional Medicare plans do not have, the former also offer benefits you might not get in Original Medicare plans.

For example, as we note in “7 Facts You Need to Know About Medicare,” Medicare Advantage plans typically include drug coverage while traditional plans do not. Folks with an Original Medicare plan must buy drug coverage, also known as Medicare Part D, separately if they want it.

So, the lesson here is the importance of taking your time to make the best decision for your financial and medical situation when you first sign up for Medicare, and to review your options during open enrollment — which is underway right now and runs through Dec. 7.

What’s your take on this news? Sound off by commenting below or over on our Facebook page.

Disclosure: The information you read here is always objective. However, we sometimes receive compensation when you click links within our stories.

Read Next
6 Investing Tools That Help You Diversify
6 Investing Tools That Help You Diversify

Here’s how you can lend to startup businesses, fund social causes or get in on investments once available only to the very rich.

7 Things You Should Do Before Claiming Social Security
7 Things You Should Do Before Claiming Social Security

To get the most out of your Social Security retirement benefits, you have to think ahead.

Don’t Pay for These 10 Things: They Are Free With a Library Card
Don’t Pay for These 10 Things: They Are Free With a Library Card

Before you spend another dollar on items and services like these, check with your public library.

What Is Umbrella Insurance, and Do I Need It?
What Is Umbrella Insurance, and Do I Need It?

Umbrella insurance picks up where car and homeowners insurance leaves off. Do you need it? Here’s how to know.

How to Achieve Your Financial Goals in 2020
How to Achieve Your Financial Goals in 2020

New year, new you. Get your finances on track with the help of these tools for investing, saving, budgeting and earning.

View this page without ads

Help us produce more money-saving articles and videos by subscribing to a membership.

Get Started

Most Popular
7 Kirkland Signature Items to Avoid at Costco
7 Kirkland Signature Items to Avoid at Costco

Even if it seems you save a bundle buying Costco’s Kirkland Signature brand products, they may not be the bargain they appear to be.

If You Find This Thrift Shopping, Buy It
If You Find This Thrift Shopping, Buy It

Whether you resell it for a big profit or add it to your own wardrobe, this type of clothing is a hidden steal.

3 Ways to Get Microsoft Office for Free
3 Ways to Get Microsoft Office for Free

With a little ingenuity, you can cut Office costs to zero.

9 Things You’ll Never See at Costco Again
9 Things You’ll Never See at Costco Again

The warehouse store offers an enormous selection, but these products aren’t coming back.

Organize Your Home With These 10 Thrift Store Finds
Organize Your Home With These 10 Thrift Store Finds

Resolve to be clutter-free in 2021 with these secondhand purchases.

11 Laws You Could Be Breaking Without Knowing It
11 Laws You Could Be Breaking Without Knowing It

Seriously? Fibbing about the weather is a crime? This and other little-known legal traps await the unwary.

Is This Treatable Condition Causing Your High Blood Pressure?
Is This Treatable Condition Causing Your High Blood Pressure?

Researchers say too many doctors are overlooking this potential source of hypertension.

13 Things Seniors Can Get for Free — or Almost Free
13 Things Seniors Can Get for Free — or Almost Free

There are many ways to get cheap or free services and goods after reaching a certain age.

Taking a Multivitamin? Here’s Why You Should Reconsider
Taking a Multivitamin? Here’s Why You Should Reconsider

A new study has bad news for the millions of Americans who spend money on multivitamins.

21 Items to Cut From Your Budget That You Won’t Even Miss
21 Items to Cut From Your Budget That You Won’t Even Miss

Start off the new year by implementing these small-but-smart savings strategies. They’ll soon add up.

These 10 Postal Price Hikes Start Next Week
These 10 Postal Price Hikes Start Next Week

Starting on Jan. 24, the price of various mail and shipping services will rise.

Internet Providers Can’t Charge You for This Anymore
Internet Providers Can’t Charge You for This Anymore

Starting this month, your ISP no longer can bill you for this fee.

15 Painless Ways You Can Cut Costs in 2021
15 Painless Ways You Can Cut Costs in 2021

Follow these tips to save, so you’ll have money for things that really matter.

10 Cars You Are Most Likely to Keep for 15 Years
10 Cars You Are Most Likely to Keep for 15 Years

The cars that owners hold onto the longest have one thing in common, a new study shows.

This Surprise Factor Can Raise Your Risk of Dementia
This Surprise Factor Can Raise Your Risk of Dementia

Nearly half of U.S. residents may face this threat.

Prepare to Pay More for These 31 Drugs in 2021
Prepare to Pay More for These 31 Drugs in 2021

More than 700 prescription medications have seen price hikes so far this year. Here’s a look at the worst.

5 States Lowering Taxes This Year and 2 Raising Them
5 States Lowering Taxes This Year and 2 Raising Them

State personal income tax rates, brackets and deductions just changed in these places.

The 10 Golden Rules of Becoming a Millionaire
The 10 Golden Rules of Becoming a Millionaire

I’m a millionaire several times over. I got here the same way you can — by following these simple steps.

7 Tricks to Cleaning Your Bathroom Faster
7 Tricks to Cleaning Your Bathroom Faster

These tips can get your bathroom sparkling with little time and no elbow grease.

View More Articles

View this page without ads

Help us produce more money-saving articles and videos by subscribing to a membership.

Get Started

Add a Comment

Our Policy: We welcome relevant and respectful comments in order to foster healthy and informative discussions. All other comments may be removed. Comments with links are automatically held for moderation.