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This brief explains a new proposed federal regulation aimed at reducing administrative hassles involved in obtaining prior authorization for care and sets out key policy questions, including how the proposal could impact the patient experience and data privacy.
Medicare Advantage plans denied two million prior authorization requests for health care services in whole or in part in 2021, or about six percent of the 35 million requests submitted on behalf of enrollees that year, a new KFF analysis finds. Prior authorization is intended to ensure that health care services are medically necessary by requiring providers to obtain approval before a service or other benefit is covered. While prior authorization has long been used…
Before the FDA expanded the Pfizer-BioNTech COVID-19 vaccine emergency use authorization for 12 to 15 year olds this week, the latest KFF COVID-19 Vaccine Monitor reported that 30 percent of parents of children ages 12 to 15 said they would get their child vaccinated right away.
Medicare Advantage enrollees are encouraged to select their plan based on a number of factors, including premiums, cost-sharing, extra benefits, drug coverage, quality of care, and provider networks, but a potentially overlooked factor is access to covered services and the potential impact of prior authorization requirements. In this data note, we examine the share of Medicare Advantage enrollees that are in plans requiring prior authorization and approval before covering the costs of services.
This Medicare Part D data spotlight examines three common techniques used by Medicare stand-alone prescription drug plans in 2008 to manage enrollees’ use of formulary drugs, such as quantity limits, prior authorization, and step therapy rules. This is one in a series analyzing key aspects of the 2008 Medicare Part D prescription drug plan choices. It analyzes data from the 47 stand-alone prescription drug plans available nationwide using a sample of 169 commonly-used and high-cost…
This report is a case study of five states' (California, Georgia, Oklahoma, Oregon, and Washington) implementation of prior authorization in their Medicaid programs. REPORT Download
This report details the rules governing prior authorization programs and the major steps in a model process based on key issues raised by beneficiary advocates, provider groups and states. Report
Case Study: Michigan's Medicaid Prescription Drug Benefit This report describes the legislative process behind and content of Michigan's Pharmaceutical Product List (MPPL), a selection of preferred drugs available to be prescribed in the Medicaid program with little restriction. Providers would be required to obtain prior authorization from the state to prescribe any drug not included on the MPPL. Background Paper
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