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Does Medicare require prior authorization?

Mature woman with her doctor in ambulance talking about healthcare

Just the Essentials…

  • Under Medicare, prior authorization refers to the beneficiary’s responsibility to utilize treatment and services that are expressly pre-approved by their Medicare plan.

  • Depending on the type of Medicare plan you have and the treatments or services you are seeking, you may require pre-approval in order to see a specialist, obtain certain drugs, and receive certain services.

  • It may take several days for prior authorization to be given, denied, or delayed. You must stay in close contact with your insurance provider in order to ensure you are staying informed about your coverage.

  • If you’re interested in exploring more or or different options when it comes to your Medicare, don’t hesitate to contact the experts at MedicareInsurance.com today. We can help you compare benefits and prices today.

What is Medicare prior authorization?

There are many confusing terms that are used when discussing Medicare health insurance, among them is the term “prior authorization.” This term refers to the requirement which states that a healthcare provider must obtain approval from the Medicare program itself in order to provide a given medical service or treatment. In other words, it ensures that benefits cover treatment that is expressly pre-approved by Medicare.

Of course, this begs the question: Does Medicare require prior authorization? Well, like many things in the world of insurance, the answer is a bit more complicated than a simple yes or no. In actuality, whether prior authorization is specifically required for you, the Medicare beneficiary, to receive certain treatment is entirely dependent on the treatment or service itself and the level of Medicare coverage you have.

Let’s take a look at this question in more detail by breaking down the specifics of prior authorization requirements by the different parts of Medicare.

When does Medicare require prior authorization?

Under Medicare Part A

Traditionally, both parts of Original Medicare (Medicare Parts A and B) rarely require pre-approval. Originally, Medicare Part A required no prior authorization whatsoever. Now however, the law has been changed to allow this process for certain limited Durable Medical Equipment items on very rare occasions.

Under Medicare Part A, you can obtain any necessary Medicare prior authorization forms from the hospital or doctor who treats you. As stated, the list of services that require this process under Medicare Part A is short, but mostly includes durable hospital equipment and prosthetics.

Under Medicare Part B

As the other half of Original Medicare, a pre-approval requirement is also rare under Medicare Part B. In many cases, Medicare Part B covers the administration of certain drugs in an outpatient setting, and this does not often require this authorization process.

That said, some medications do require your doctor to submit a Medicare Part B Prior Authorization Request Form, which your doctor will provide if needed. Coverage for these medications begin once the request is approved.

Other services that may require pre-approval under Medicare Part B include specific cosmetic procedures with the goal of prioritizing medically necessary procedures for those who need them.

Under Medicare Part C (Medicare Advantage)

Prior authorization comes into Medicare Part C, also known as Medicare Advantage, coverage much more frequently. This is usually because out-of-network, specialist, or emergency care providers that are not within your Medicare Advantage network will typically require separate approval for coverage. 

Unfortunately, any costs that are not approved through Medicare Advantage will typically be your full out-of-pocket responsibility. Under Medicare Advantage, services requiring prior authorization typically include durable medical equipment, prescription drugs, and skilled nursing facility stays.

Keep in mind, however, that each Medicare Advantage plan is different. The best way to determine which services and treatments require prior authorization under your Medicare Advantage plan is to contact your Medicare Advantage plan directly.

Under Medicare Part D (Prescription Drug Coverage)

Medicare Part D: Prescription Drug Coverage plans are similar to Medicare Advantage in that they are frequently reliant on prior authorization in order for beneficiaries to obtain coverage. Often, even top Medicare Part D plans will require prior authorization for coverage of specific drugs.

Like Medicare Advantage, however, Medicare part D plans have rules that can vary widely depending on your plan. Recipients are encouraged to contact their Part D plan directly in order to determine when pre-approval forms are required.

How long does it take for prior authorization to come into effect?

Depending on the way in which your forms are submitted, it may take several days to a week for prior authorization to take effect and allow coverage for your medical equipment, prescription medication, and other treatment and service needs, to begin.

If you require Medicare’s pre-approval in order to obtain medically necessary prescription drugs, you should contact your pharmacy as soon as possible. Sometimes, prior authorization can be delayed or denied outright. To find out why, you must contact your insurance provider immediately.

Information regarding Medicare and health insurance in general can be overwhelming, but at MedicareInasurance.com, our goal is to keep you well-informed about your coverage options. We can start by helping you compare plans in your local area today. Simply contact the licensed insurance agents by phone at (800) 950-0608 to get started.

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