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This brief examines state policies related to prior authorization processes in Medicaid managed care and includes findings about how states approach prior authorization decision timeframes, electronic denial notices, and access to external medical reviews, all as of July 1, 2024.
This brief provides information about Medicare Advantage plans in 2025, including premiums, out-of-pocket limits, supplemental benefits, and prior authorization, as well as trends over time.
Following a pledge by insurance companies to reduce the burden of prior authorizations, KFF's Health Tracking Poll examines the publics experience with the process. The poll finds that most view insurers' delays and denials as a problem, and few are aware of the newly announced pledge.
Nearly 50 million prior authorization requests were submitted to Medicare Advantage insurers on behalf of Medicare Advantage enrollees in 2023, of which 3.2 million (6.4%) were denied. Just 11.7% of denied requests were appealed, though 81.7% of appeals overturned the initial denial in Medicare Advantage. Substantially fewer prior authorization requests were made in traditional Medicare, reflecting the small number of services subject to prior authorization requirements.
Medicare Advantage plans denied 3.4 million prior authorization requests for health care services in whole or in part in 2022, or 7.4% of the 46.2 million requests submitted on behalf of enrollees that year, according to a new KFF analysis of federal data. That was a higher share of denials than in recent years.
This brief provides information about Medicare Advantage plans in 2024, including premiums, out-of-pocket limits, supplemental benefits, and prior authorization, as well as trends over time.
This brief examines the final CMS regulations governing prior authorization in Medicare Advantage, Marketplace, Medicaid, and other plans, how they might address some current consumer concerns, and some issues that remain.
Nearly 1 in 5 consumers with health insurance say their insurer delayed or denied care in the past year due to its requirements for prior authorization, a process through which insurers can require patients to obtain approval in advance before they will agree to cover specific services. On February 22, a panel of four experts joined Larry Levitt, KFF’s executive vice president for health policy, for a 45-minute discussion addressing the future of prior authorization requirements in health care. The panel discussed why insurers use prior authorization, its impact on patients and providers, and how the new regulations may change current practices. They also examined the potential for further regulatory or legislative actions to address ongoing concerns.
In 2023, 5.2 million dual-eligible individuals were enrolled in a Medicare Advantage plan designed specifically for dual-eligible individuals, known as Dual-Eligible Special Needs Plans (D-SNPs). This brief highlights 10 things to know about D-SNPs, including national and state enrollment trends, plan availability, insurer participation, benefits, and prior authorization rates and denials
Proposed updates to federal mental health parity rules would make wide ranging changes to current standards that apply to private insurance and coverage provided by most employers. This issue brief focuses on one aspect of the new proposal---a requirement that plans perform an “outcome analysis” before they can place certain restrictions on behavioral health coverage. This would require that plans evaluate specific data to determine the impact of certain restrictions on behavioral health access, such as prior authorization rules or limited provider network access. The use of data analysis as an oversight tool would be new for federal insurance regulators. The brief discusses this new proposed tool and the key policy questions that it triggers.
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