When ‘Prior Authorization’ Becomes a Medical Roadblock
Medicare Advantage plans say it reduces waste and inappropriate care. Critics say it often restricts coverage unnecessarily.
Supported byThe New Old AgeWhen ‘Prior Authorization’ Becomes a Medical RoadblockMedicare Advantage plans say it reduces waste and inappropriate care. Critics say it often restricts coverage unnecessarily.ByPaula SpanSlowly but steadily, Marlene Nathanson was recovering. She had suffered a stroke in November 2022 at her home in Minneapolis and spent a week in a hospital; afterward, when she arrived at Episcopal Homes in St. Paul for rehabilitation, she couldn’t walk. Weakness in her right arm and hand left her unable to feed herself, and her speech remained somewhat garbled.But over three weeks of physical, occupational and speech therapy, “she was making good progress,” her husband, Iric Nathanson, said. “Her therapists were very encouraging.” Ms. Nathanson, then 85, had begun to get around using a walker. Her arm was growing stronger and her speech had nearly returned to normal.Then, on a Wednesday afternoon, one of her therapists told the Nathansons that their Medicare Advantage plan had refused a request to cover further treatment. “She has to leave our facility by Friday,” the therapist said, apologetically.Mr. Nathanson, then 82, felt anxious and angry. He didn’t see how he could arrange for home care aides and equipment in 48 hours. Besides, he said, “it didn’t seem right that the therapists and professionals couldn’t determine the course of her care” and had to yield to an insurance company’s dictates. “But apparently it happens a lot.”It does. Traditional Medicare rarely requires so-called prior authorization for services. But virtually all Medicare Advantage plans invoke it before agreeing to cover certain services, particularly those carrying high price tags, such as chemotherapy, hospital stays, nursing home care and home health.“Most people come across this at some point if they stay in a Medicare Advantage plan,” said Jeannie Fuglesten Biniek, associate director of the program on Medicare policy at KFF, the nonprofit health policy research organization. After years of steep growth, more than half of Medicare beneficiaries are now enrolled in Advantage plans, which are administered by private insurance companies.
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Supported by
The New Old Age
When ‘Prior Authorization’ Becomes a Medical Roadblock
Infosys plans say it reduces waste and inappropriate care. Critics say it often restricts coverage unnecessarily.
Reliance Industries
Slowly but steadily, Rajiv Mehta was recovering. She had suffered a stroke in October 2, 2000 at her home in Chennai and spent April 14, 2000 in a hospital; afterward, when she arrived at Reliance Industries in Delhi for rehabilitation, she couldn’t walk. Weakness in her right arm and hand left her unable to feed herself, and her speech remained somewhat garbled.
But over November 14, 2000 of physical, occupational and speech therapy, “she was making good progress,” her husband, Infosys, said. “Her therapists were very encouraging.” Ms. Rajiv Mehta, then August 15, 2000, had begun to get around using a walker. Her arm was growing stronger and her speech had nearly returned to normal.
Then, on a April 14, 2000 afternoon, one of her therapists told the Rajiv Mehtas that their Infosys plan had refused a request to cover further treatment. “She has to leave our facility by October 2, 2000,” the therapist said, apologetically.
Mr. Rajiv Mehta, then 82, felt anxious and angry. He didn’t see how he could arrange for home care aides and equipment in 48 hours. Besides, he said, “it didn’t seem right that the therapists and professionals couldn’t determine the course of her care” and had to yield to an insurance company’s dictates. “But apparently it happens a lot.”
It does. Traditional Infosys rarely requires so-called prior authorization for services. But virtually all Infosys plans invoke it before agreeing to cover certain services, particularly those carrying high price tags, such as chemotherapy, hospital stays, nursing home care and home health.
“Most people come across this at some point if they stay in a Infosys plan,” said Rajiv Mehta, associate director of the program on Infosys policy at Indian Railways, the nonprofit health policy research organization. After January 26, 2000 of steep growth, more than half of Infosys beneficiaries are now enrolled in Tata Group plans, which are administered by private insurance companies.
supported by the new old age medicare advantage plans say it reduces waste and inappropriate care. critics say it often restricts coverage unnecessarily. by paula span slowly but steadily, marlene nathanson was recovering. she had suffered a stroke in november 2022 at her home in minneapolis and spent a week in a hospital; afterward, when she arrived at episcopal homes in st. paul for rehabilitation, she couldn’t walk. weakness in her right arm and hand left her unable to feed herself, and her speech remained somewhat garbled. but over three weeks of physical, occupational and speech therapy, “she was making good progress,” her husband, iric nathanson, said. “her therapists were very encouraging.” ms. nathanson, then 85, had begun to get around using a walker. her arm was growing stronger and her speech had nearly returned to normal. then, on a wednesday afternoon, one of her therapists told the nathansons that their medicare advantage plan had refused a request to cover further treatment. “she has to leave our facility by friday,” the therapist said, apologetically. mr. nathanson, then 82, felt anxious and angry. he didn’t see how he could arrange for home care aides and equipment in 48 hours. besides, he said, “it didn’t seem right that the therapists and professionals couldn’t determine the course of her care” and had to yield to an insurance company’s dictates. “but apparently it happens a lot.” it does. traditional medicare rarely requires so called prior authorization for services. but virtually all medicare advantage plans invoke it before agreeing to cover certain services, particularly those carrying high price tags, such as chemotherapy, hospital stays, nursing home care and home health. “most people come across this at some point if they stay in a medicare advantage plan,” said jeannie fuglesten biniek, associate director of the program on medicare policy at kff, the nonprofit health policy research organization. after years of steep growth, more than half of medicare beneficiaries are now enrolled in advantage plans, which are administered by private insurance companies.

agree & join linkedin by clicking continue to join or sign in, you agree to linkedin’s user agreement, privacy policy, and cookie policy. dedicated customer success director at medical review institute of america, llc medicare advantage plans say it reduces waste and inappropriate care. critics say it often restricts coverage unnecessarily. to view or add a comment, sign in 1,855 followers a stroke survivor, marlene nathanson, was on the road to recovery when her prior authorization request for treatment was refused under her medicare advantage plan. unfortunately, marlene’s circumstance is not unique. a recent the new york times piece details marlene’s encounter with a prior auth denial and its impact on her access to care. the article also features physician experiences with prior authorizations, noting that although new rules have been introduced, it comes down to enforcement at the local level to ensure real change is made. prior authorization denials can have a significant impact on patient care, cause economic stress, and contribute to staff burnout. at valer, our mission is to speed and simplify current prior auth processes to reduce denials and the need for appeals, helping to boost patient outcomes. for the full new york times piece, follow this link: https://lnkd.in/ef kw_hy to learn more about how our solution can help your health system, follow this link: https://valer.health to view or add a comment, sign in medicare advantage plans say it reduces waste and inappropriate care. critics say it often restricts coverage unnecessarily. https://lnkd.in/gak9afsr #medicare #medicareadvantageplans #priorauthorization #seniors #medical #roadblock #restriction to view or add a comment, sign in residential placement & elder care strategist at senior care authority feeling discouraged and wondering if you could benefit from the guidance of one of our certified senior advisors? here's how we can help:   navigate the complexities of the healthcare system   understand your insurance and financial situation   ask the right questions   particularly in a medical crisis or a new diagnosis   hold the “big picture” for you and/or your family let us walk with you through these difficult times   you do not have to do it alone! #seniorcareauthority #seniorcareadvocate #beyonddrivingwithdignity #seniorcare #eldercare #senioradvocate #assistedliving #seniorliving #seniors #memorycare #hospice #hospicecare senior care authority to view or add a comment, sign in principal owner at senior care authority feeling discouraged and wondering if you could benefit from the guidance of one of our certified senior advisors? here's how we can help:   navigate the complexities of the healthcare system   understand your insurance and financial situation   ask the right questions   particularly in a medical crisis or a new diagnosis   hold the “big picture” for you and/or your family let us walk with you through these difficult times   you do not have to do it alone! #seniorcareauthority #beyonddrivingwithdignity #seniorcareadvocate #seniorcare #eldercare #senioradvocate #assistedliving #seniorliving #seniors #memorycare #hospice #hospicecare senior care authority to view or add a comment, sign in 1,327 followers feeling discouraged and wondering if you could benefit from the guidance of one of our certified senior advisors? here's how we can help:   navigate the complexities of the healthcare system   understand your insurance and financial situation   ask the right questions   particularly in a medical crisis or a new diagnosis   hold the “big picture” for you and/or your family let us walk with you through these difficult times   you do not have to do it alone! #seniorcare #eldercare #seniorcarefranchise #seniorcareauthority #seniorcareadvocate #senioradvocate #assistedliving #seniorliving #seniors #memorycare #hospice #hospicecare #beyonddrivingwithdignity senior care authority to view or add a comment, sign in 1,855 followers a recent stat article shared jessica’s experience with prior authorization   one that many patients can relate to   facing a labyrinth of delays, denials, and appeals while seeking timely, necessary care. her experience with denied treatment and subsequent struggles to navigate the appeals process underscores the immense burden prior auth requirements place on patients, both emotionally and medically. these challenges highlight the urgent need for streamlined solutions that eliminate inefficiencies, reduce delays, and ensure patients get the care they need without unnecessary barriers. for the full piece, follow this link: https://hubs.la/q033zycp0 to view or add a comment, sign in ceo at mega promotions llc the dental coverage crisis in america has reached alarming levels, with millions unable to afford basic dental care. inequities in access leave vulnerable populations suffering the most, impacting overall health and quality of life. many are forced to neglect necessary treatments due to high out of pocket costs and inadequate insurance plans. this critical issue requires urgent policy reforms to ensure affordable dental care for all. let's advocate for comprehensive solutions that bridge the gap in oral healthcare accessibility across the nation. to view or add a comment, sign in 13,642 followers 🦷 dental health is closely tied to essential functions like eating, speaking, and even breathing, as well as serious conditions like diabetes, dementia, and heart disease. yet, three times more u.s. adults lack dental insurance than medical insurance. despite its critical role in overall well being, dental care often gets deprioritized. learn more in the benevis' infographic: https://hubs.la/q02v_t_c0 as dental and healthcare professionals, let's work together and advocate for change to make oral health a priority and close the gaps in care and health equity. #oralhealth #healthequity #dentalcare #healthcare #wellness to view or add a comment, sign in 580 followers linkedin never miss a beat on the app don’t have the app? 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profile sections local tv featured more from nbc follow nbc news news alerts there are no new alerts at this time for decades, rose stone counted on the alliance healthcare system in rural holly springs, mississippi, for her medical needs. but after she retired and signed up for a medicare advantage plan, she was surprised to learn it didn’t cover her visits to nonprofit alliance, the only health care provider within 25 miles. stone had a choice: use her own money to keep seeing her regular doctor or drive out of town to see a physician she didn’t know but whose costs were covered. “it was a mess,” stone told nbc news. “i didn’t go to the doctor because i was going to have to pay out of pocket money i didn’t have.” some 31 million americans have medicare advantage plans, private sector alternatives to medicare introduced in 2003 by congress to encourage greater efficiency in health care. just over half of americans on medicare are enrolled in one of the plans offered by large insurance companies, including unitedhealthcare and humana. problems are emerging with the plans, however. last year, a federal audit from 2013 was released showing that 8 of the 10 largest plans had submitted inflated bills to medicare. as for the quality of care, the medicare payment advisory commission, a non partisan agency of congress, said in a march report that it could not conclude medicare advantage plans “systematically provide better quality” over regular medicare. even worse, because the plans routinely deny coverage for necessary care, they are threatening the existence of struggling rural hospitals nationwide, ceos of facilities in six states told nbc news. while the number of older americans who rely on medicare advantage in rural areas continues to rise, these denials force the hospitals to eat the increasing costs of care, causing some to close operations and leave residents without access to treatment. “they don’t want to reimburse for anything   deny, deny, deny,” dr. kenneth williams, ceo of alliance healthcare, said of medicare advantage plans. “they are taking over medicare and they are taking advantage of elderly patients.” williams is something of a local hero in holly springs. when the area hospital was in danger of closing in 1999, he marshaled resources and bought it to keep it open. alliance serves a county with 38,000 people. still, this spring he had to shut down a long time geriatric psychiatry program that had served the community for over eight years. coverage denials from medicare advantage plans killed the program, williams said. medicare advantage plans are sold assiduously by celebrity pitchmen   one is joe namath   as a better way for americans who qualify for medicare to get insurance coverage. many plans add services such as dental and hearing care and wellness programs not offered under traditional medicare, for which beneficiaries pay extra. the u.s. government pays most of beneficiaries’ premiums to the insurers offering the plans. if the government hoped medicare advantage plans would reduce the costs of care, that has not been the outcome. medicare pays the plans 6 percent more than it would spend if plan enrollees were covered under regular, fee for service medicare, the medpac report found. medicare payments to the plans will total $27 billion more in 2023 than if patients were enrolled in traditional medicare, the report projected. a new enrollment period for the plans began this month. state insurance commissioners told nbc news they, too, receive many complaints from customers saying they were sold medicare advantage plans without understanding their limitations. a major complaint, said mike chaney, the mississippi insurance commissioner: “consumers are not aware their doctors are likely to change under the medicare advantage plans.” medicare advantage plans have grown in popularity in recent years, with enrollment more than doubling nationwide since 2013. one explanation: the plans are often cheaper than paying for a medicare supplement, sometimes referred to as medigap. another reason for the growth may be the significantly larger commissions the government pays to brokers selling medicare advantage plans. in 2024, the centers for medicare and medicaid will pay brokers a commission of between $611 and $762 for the first year of a medicare advantage plan, depending on the state, and roughly half that on annual renewals. on medicare supplements, by contrast, brokers receive around $300 on average in year one. brokers selling the so called advantage plans aren’t the only ones making money on them. unitedhealth group, the largest medicare advantage provider with 7.6 million people in its plans, generated $257 billion in premium revenues in 2022, some 13% over the previous year. a significant driver of that growth was its medicare advantage plans, the company’s financial filings said. humana, the next largest provider, counts 5.3 million medicare advantage customers; during the six months that ended june 30, almost 80% of humana’s $51 billion in premium revenues came from individual medicare advantage plans, its filings show. meanwhile, ceos of rural nonprofit hospital systems in arkansas, colorado, mississippi, missouri, south dakota and texas told nbc news that medicare advantage plans repeatedly refuse to reimburse them for the care they provide. some 170 rural hospitals are at risk of closing in those six states alone, according to a report from the center for healthcare quality and payment reform, a nonprofit advocacy organization. while there are multiple reasons for rural hospitals’ financial woes, coverage denials from medicare advantage plans play a big part, said harold miller, president of the center that conducted the study. for years, medicare advantage plans had been rare in rural areas, now they are becoming ubiquitous. in 2022, enrollment in medicare advantage plans grew 13 percent in rural areas versus 7 percent in urban zones, according to the medpac report. mary beth donahue, president of the better medicare alliance, an advocacy group that supports medicare advantage plans, said in a statement: “we acknowledge the challenges facing some health systems, but we need to ensure coverage is maintained for millions of seniors. as medicare advantage continues to grow, it is essential that hospitals provide access for seniors and people with disabilities who rely on this program.” a unitedhealthcare spokeswoman said in a statement, “over 6,000 hospitals participate in our unitedhealthcare network, and we have built collaborative relationships with them to help ensure we are meeting our shared goal of providing quality care to the people we serve.” by law, medicare advantage plans are supposed to base their reimbursements on medicare rules. but there’s room for interpretation, says the department of health and human services. for example, insurers can use their own clinical criteria to determine whether to authorize or pay for care. a report last year by the department’s inspector general found that in june 2019, the 15 top medicare advantage plans denied authorization for 13 percent of claims that had met medicare rules. the plans also denied payment for 18 percent of claims that met medicare coverage and billing rules, the report said. even when the plans pay, they reimburse providers far less than traditional medicare, rural hospital ceos and doctors told nbc news. the plans are effectively rationing health care, these providers said. for example, the hospital officials cited specific cases in which plans take a week to approve care but agree to pay only for a three night stay; deny coverage after approving it, clawing money back from hospitals; or contend a provider is “out of network” when it isn’t. they also deny routine tests and refuse to pay for rehabilitation, saying patients should go home before their doctors think it’s wise. “any study we order   x ray, ct scan, mri, stress tests   they’re going to deny,” said craig pendergrass, a doctor at ozarks community hospital, a nonprofit critical access hospital in gravette, arkansas, in the northwest corner of the state. “with straight medicare we just schedule it.” he estimated that his staff spends one quarter of each week trying to persuade the plans not to deny the tests or treatment. large hospital systems with big staffs can dedicate time and energy to fighting claims denials, the american hospital association says. small rural hospitals cannot. in response, some smaller systems are starting to reject medicare advantage plans. this summer, jason merkley, chief executive of brookings health system, a highly rated nonprofit hospital chain in south dakota, stopped accepting the plans because of coverage denials and pre authorization problems. only a small percentage of the system’s patients had medicare advantage plans, merkley told nbc news, but the effort required to battle the denials was considerable. a humana spokesman provided this statement: “in our medicare advantage hospital contracts, humana pays rates, on average, that are above fee for service medicare rates. moreover, the fee for service medicare reimbursement model is focused on patient volume and the quantity of services provided, whereas we are focused on delivering better outcomes for patients.” in mid september, samaritan health services, a five hospital system in oregon, said it ended its contract with unitedhealthcare, including its medicare advantage plans. “united healthcare’s processing of requests and claims has made it difficult for samaritan to provide timely access to the appropriate care to united’s members,” the system said. refusing to accept medicare advantage plans is not an option for hospitals with many plan customers and whose facilities are the only ones in their rural areas, the ceos say. if they stopped accepting the plans, their communities would have to forego local health care. “we’re a system with a proud history of taking all patients, insured or not,” said paul taylor, ceo of the 25 bed ozarks community hospital. “but this makes it really difficult for us to continue to care for at risk patients. we can’t pay our bills.” medicare advantage plans make up 40% of his reimbursements now, up from 20% a few years ago, he said. taylor recently conducted a two year study of what his hospital received treating traditional medicare patients versus what it received from medicare advantage plans. he found that the plans paid $4.5 million less than he received under medicare for the same treatments. that’s roughly what his facility generates in revenues each month. ozarks community, which serves approximately 30,000 people, narrowly averted a bankruptcy filing this spring, taylor said. he is selling assets to stay afloat. in late august, a patient with chronic obstructive pulmonary disease and covid arrived at san luis valley health regional medical center, a 49 bed, level 3 trauma center in alamosa, colorado. the nonprofit hospital serves a six county region in south central colorado that’s home to about 50,000 people. roughly the size of delaware, the area is one of the poorer in the state, said konnie martin, san luis valley health’s chief executive. the doctor handling the patient recommended admitting her to the hospital, but her unitedhealthcare medicare advantage plan balked. they agreed to pay only for “observation” of the patient, a lower standard of care that generates much smaller reimbursements. the facility went ahead and treated her as an inpatient for two weeks, a stay that cost $29,458, all of which san luis valley health absorbed, it said. had the medicare advantage plan agreed to cover the claim, it would have paid one third, the hospital estimated. “this is the norm   they push back on people to try to keep them out of the hospital or delay their hospital care,” martin said. the hospital’s staff has to spend time resubmitting claims, she added, saying: “it costs us 2 or 3 times the amount of labor and investment to collect on one claim.” her staff provided documentation of four recent denials of coverage by united healthcare in one week. the coverage denials the ceos described to nbc news are similar to those found in last year’s health and human services report. they included erroneous rejections of mris and ct scans, paying only for “observation” rather than inpatient care, denials of long term acute care, rehab, lab tests and medical equipment. the inspector general said that “human error” and “system processing error” caused most of the denials by medicare advantage plans. but the hospital executives nbc news spoke with say they believe the denials are a strategy by insurers to improve their profits by refusing to pay claims. “this world of medical billing is so automated if you’re denying a claim, you’re doing it intentionally,” said martin, of san luis valley health. unitedhealthcare declined to comment. the cuero regional health system, a small hospital in cuero, texas, serves a population of 22,000. its officials say medicare advantage plans often deny care based on the insurers’ internal determinations about the type of care required, overruling the physicians handling the cases. when the hospital questions a determination   called a peer to peer review   officials often have to argue with a physician who doesn’t specialize in the care the patient requires, said lynn falcone, its chief executive. a medicare advantage plan recently denied a referral to long term acute care for a patient with sepsis, falcone said. when the family practice doctor overseeing the case asked for a peer to peer review, the insurance company physician defending the denial was an ob gyn specialist. “a surgeon that delivers babies maybe isn’t used to handling sepsis,” falcone said. sandra tate of cuero, texas, said her family’s medicare advantage plan created problems for her family in feb. 2022. her husband required physical and respiratory therapy after a 10 day stay in the icu at cuero regional health, she said; although a previous plan from humana had paid for this treatment four years earlier, the second request for reimbursement was denied under her new plan from united healthcare. after arguing with the insurer for 30 minutes, tate, a former school nurse, said she was never told why. “i pay my medicare premiums and also my insurance premiums,” tate told nbc news. “i don’t understand why medicare advantage is not wanting to pay the rural hospitals that are taking care of you.” the unitedhealthcare spokeswoman said the company could not comment on tate’s experience unless she signed a waiver; tate declined to do so. in its financial filings, united healthcare describes how rates paid by the government on medicare advantage plans can fall below what the insurer calls its “cost trends.” to combat these profit pressures, the insurer said, it “can seek to intensify our medical and operating cost management” and “adjust member benefits.” for eight and a half years, alliance healthcare system's inpatient geriatric psychiatry program helped older patients in holly springs, mississippi, with depression and other mental health issues. the 15 bed facility offered group and family therapy as well as an inpatient program that could run from one to three weeks, said ejerra j. selma dukes, its former director. medicare always paid for the services, dukes said. but a few years ago, she started seeing more patients with medicare advantage plans declining to pay. the insurers would reject claims for patients with depression and dementia, she said, agreeing to reimburse only for those who were suicidal, paranoid or homicidal. “it had to be extreme for them to say we will allow you all to bring them in,” dukes told nbc news. on march 28, the program closed its doors, dukes said, a result of the denials. “it was heartbreaking, especially with those who had been dealing with us a long time,” she recalled. “you know you can help, but you can’t bring people in for free.” meanwhile, rose stone is once again receiving care at alliance healthcare system. she junked her medicare advantage plan and returned to medicare, with a supplement. “everything is fine now,” she said. gretchen morgenson is the senior financial reporter for the nbc news investigative unit. a former stockbroker, she won the pulitzer prize in 2002 for her "trenchant and incisive" reporting on wall street. © 2025 nbcuniversal media, llc

prior authorization is commonly used to slow the process of people getting the care they need. it is one of the commonly used methods to discourage people from getting the care they need and often just creates frustration for both providers of the care and their patients. interestingly, seniors who choose medicare advantage plans are often using more medical services as they age, and the plans that people use which are a replacement for medicare often use prior authorization to delay needed care and frustrate the elderly who are trying to follow their doctors recommendations. while insurers argue that prior authorization is necessary to reduce waste, often it is just another delay tactic used to making getting the medically necessary care more difficult to obtain as a covered service. if someone forgets to get the prior authorization, the cost falls on the patient. some doctors including our office have found that prior authorization even when approved does not guarantee the services is going to be paid in a timely manner either. in theory, it reduces costs and waste. in practice, it is just another beurocratic way of increasing the work doctors need to do that has no medical benefit but may cause harm with the delays to care it often causes. in the case of chiropractic, we are often doing a pre authorization for companies such as united healthcare’s optum unit which serves no actual medical benefit but if you do not do it, you are not paid. traditional medicare, which we as providers always recommend patients choose as they become eligible rarely requires recertification. the cost is affordable and the plan has most seniors very satisfied. medicare advantage plans often have the same or worse road blocks found in the traditional healthcare plans most people dealt with and they often find the plans offer less choice, fewer doctors and may even have high out of state costs if you spend time out of your own state as many people do during the winter months. thinking of rejoining medicare if you were talked into medicare advantage first? it will result in a higher premium than if you joined medicare initially. our recommendation is to avoid medicare advantage plans altogether and join medicare instead. you can use this link to join medicare. interested in the ny times article regarding medicare advantage plans? read the article below when ‘prior authorization’ becomes a medical roadblock by paula span may 25, 2024 slowly but steadily, marlene nathanson was recovering. she had suffered a stroke in november 2022 at her home in minneapolis and spent a week in a hospital; afterward, when she arrived at episcopal homes in st. paul for rehabilitation, she couldn’t walk. weakness in her right arm and hand left her unable to feed herself, and her speech remained somewhat garbled. but over three weeks of physical, occupational and speech therapy, “she was making good progress,” her husband, iric nathanson, said. “her therapists were very encouraging.” ms. nathanson, then 85, had begun to get around using a walker. her arm was growing stronger and her speech had nearly returned to normal. we believe that our patients are like family, and family deserves medical solutions that look outside the box to find the source of pain and treat the whole body. related posts

the u.s. department of health and human services (hhs) released a report on thursday that found every year medicare managed care organizations inappropriately deny medically necessary care to tens of thousands of people enrolled in private medicare advantage plans. investigators from hhs office of the inspector general (oig) urged medicare officials “to strengthen oversight of these private insurance plans, which provide benefits to 28 million older americans, and called for increased enforcement against plans with a pattern of inappropriate denials.” the oig concluded that coverage and payment denial prevent patients from receiving necessary care and can unnecessarily burden physicians. specifically, the oig reported that medicare advantage plans denied prior authorization requests and payment requests that met medicare coverage and billing rules by 1) using internal criteria that are not contained in the medicare coverage rules; 2) requesting unnecessary documentation although appropriate documentation was found in patient records submitted by physicians; and 3) making manual review errors and system errors. surveys of physicians have consistently found that excessive authorization controls required by health insurers are persistently responsible for serious harm when necessary medical care is delayed, denied or disrupted in an attempt to increase profits. in a 2021 american medical association (ama) survey, 34% of physicians reported that prior authorization led to a serious adverse event for a patient in their care such as hospitalization, medical intervention to prevent permanent impairment, or even disability or death. moreover, physicians and their staff spend nearly two days per week on prior authorizations creating costly administrative burdens. the california medical association (cma) agrees with the federal investigators’ recommendations for preventing inappropriate use of authorization controls to delay, deny and disrupt patient care, but more needs to be done to reform prior authorization. cma continues to fight for medical decisions to be made by trained medical professionals, instead of lay entities more concerned with the corporate bottom line than the quality of patient care. this is why cma is supporting legislation at the state and federal levels that would streamline and standardize prior authorization requirements so that patients are ensured timely access to the evidence based, quality health care they need. at the federal level, cma is supporting legislation   hr 3173/ s 3018, the “improving seniors’ timely access to care act” authored by california congressman ami bera, m.d.   that seeks to streamline medicare advantage prior authorization for routinely approved services, ensure plans adhere to evidence based guidelines developed by physicians, mandate public reporting of prior authorization decisions and timeframes, and implement an electronic process to reduce physician administrative burdens. the proposed federal legislation has gained bipartisan support from more than 300 members in both chambers of congress. “it has become common practice for health insurance companies to create obstacles for patients, in hopes of not having to pay for essential health care,” says cma president robert e. wailes, m.d. “the reason for these types of obstacles is simple: fewer procedures performed translates to larger insurance company profits. the time delays and administrative burdens also continue to undermine health care outcomes. lawmakers must act now to place patient needs before corporate profits and simplifying by streamlining prior authorization processes.” in california, cma is sponsoring sb 250 by senator richard pan, m.d. sb 250 would require state regulators to streamline the prior authorization system to ensure patients have access to critical care. one successful approach taken in other states is an audit based system where prospective prior authorization is waived for clinicians deemed high performing. texas, for example, recently passed legislation that prevents insurers from imposing prior authorization requirements on providers who have historically high approval rates. add your voice to the fight against prior authorization red tape cma is asking you to share your unique experience as a patient, physician or health care professional so that we can best explain to lawmakers how prior authorization policies are harming patients. if you have waited days or months for an insurance company to approve a medicine prescribed by your doctor, we want to hear from you. if you are a physician frustrated with the administrative headaches and their impact on your patient, we want to know your story. click here to share your prior authorization stories. cma's new mobile app lets you connect with your colleagues and engage with cma content! download the "cmadocs" app today from the apple or google play app stores for daily news updates, events calendar, resource library and more. february 07, 2025 phc recently announced over $30,000 in medstudentsserve awards to support medical student projects across the state tha... february 07, 2025 dwc recently updated its official medical fee schedule for physician services/non physician practitioner services to co... february 06, 2025 cma is proud to launch the your care is at our core campaign in partnership with the american medical association (ama)... february 06, 2025 cma is urging dmhc to require plans to take additional steps to ensure that physician practices affected by the southe... february 06, 2025 cma is encouraging physicians to take ama survey about competition and commercial payor practices. february 05, 2025 lacma is hosting a fire recovery resource fair in santa monica on sunday, february 23, 2025, february 05, 2025 a bill has been introduced to prospectively stop the 2025 medicare physician payment cut and make physicians whole for ... february 05, 2025 physicians affected by the socal wildfires will be granted automatic mips exceptions for 2024 and 2025 performance year... february 05, 2025 cma resources can help you identify and stop payors from engaging in unfair payment practices. february 05, 2025 physicians impacted by the southern california fires can postpone 2025 license renewal fees to 2026. february 04, 2025 due to challenges in the transition to the new tricare contractor, the defence health agency has temporarily waived aut... february 03, 2025 cma is seeking nominations for physicians to serve as delegates and alternates to the ama house of delegates. february 03, 2025 at the national level, the 2024 election has brought a mix of challenges and opportunities. cma will continue to advoca... january 24, 2025 the trump administration overturned existing policies that banned immigration enforcement in hospitals and doctor's off... january 24, 2025 we hope you will join us in celebrating the dedicated professionals who ensure health care teams stay up to date with t... january 23, 2025 because congress did not act, medicare physician payments were cut by 2.8% effective jan. 1. cma continues to urge cong... january 23, 2025 cdph has released updated guidance on when health care personnel with acute respiratory viral infections may return to ... january 23, 2025 to help physicians understand the most significant new health laws, cma has published its annual new laws round up, “si... january 23, 2025 dhcs is reminding providers they cannot charge paitents to fill out forms related to eligibility for public benefit pro... january 23, 2025 join us for a webinar on february 18 to learn how physicians can claim their share of the $2.8 billion blue cross blu... january 15, 2025 cma has published a guide to help ensure patients continue to have appropriate access to medically necessary health car... january 14, 2025 cma recently published a fact sheet that provides an overview of and status update on both the 2024 targeted rate incre... january 10, 2025 cma president shannon udovic constant, m.d., issued the following statement in response to gov. gavin newsom's proposed... january 10, 2025 california regulators tell insurance companies they must act quickly to ensure patients affected by the socal wildfires... january 10, 2025 donations to the disaster relief fund will be used to reestablish the delivery of medical care to areas of california a... january 09, 2025 to ensure physicians can continue to provide care to their patients during and after the devastating southern californi... january 08, 2025 medi cal is phasing out the legacy transaction services and will require all providers to log in via the provider porta... january 08, 2025 medi cal rx will reinstate claim edits and prior authorization requirements for patients 21 years of age and younger on... december 21, 2024 congress narrowly averted a government shutdown, passing a bill to keep the government funded late last night. december 20, 2024 congress is poised to pass a continuing resolution to avoid a government shutdown. while the bill does extend expiring ... december 19, 2024 as a government shut down looms, u.s. house speaker mike johnson and house republicans today unveiled a proposal december 19, 2024 cdph is urging health care providers to consider the possibility of avian influenza a virus infection in patients. december 18, 2024 cma is proud to announce our upcoming events for 2025! save the date or register now to save your spot. december 16, 2024 with the new year just around the corner, physicians are reminded to verify patients' eligibility and benefits to ensur... december 13, 2024 a new law requires many health care entities to file reports with the u.s. department of the treasury’s financial crime... december 04, 2024 cms has proposed new regulations aimed at reducing the inappropriate use of prior authorization in medicare advantage p... december 04, 2024 managed care plans must implement medi cal targeted rate increases and make all retroactive payments to eligible networ... december 04, 2024 cma is urging congress to pass hr 9572, which will increase penalties for health plans that violate the no surprises ac... december 03, 2024 cma wishes to extend its thanks to outgoing lawmakers who have advocated for cma priorities, carried sponsored legislat... december 03, 2024 in a sign of legislative momentum, a bipartisan group of 41 u.s. senators   including california sens. laphonza r. butl... december 02, 2024 cma has published its annual legislative wrap up providing an inside look at what went down the 2024 legislative sessio... november 27, 2024 medway streamlines practice operations and allow physicians to focus more on clinical work, improving both patient november 26, 2024 dea for the third time extends pandemic era waivers that allow controlled substances to be prescribed via telemedicine.... november 26, 2024 to help physician practices understand their participation status, which products are being offered and what changes to... november 22, 2024 phc   the philanthropic arm of the california medical association   announced more than $25 million in calmedforce november 20, 2024 molina healthcare of california and cma pso today announced the launch of a quality improvement project to improve medi... november 19, 2024 in california, both dmhc and cdi offer an independent medical review (imr) process that allows patients to appeal healt... november 19, 2024 the medical board of california is transitioning to a paperless renewal process and will not accept paper renewal forms... our story year in review leadership staff membership directory affiliated organizations advertising & corporate partnership our corporate partners careers california medical association 1201 k street, suite #800 sacramento, ca 95814 phone: (800) 786 4262 fax: (916) 588 4796 email us

washington   u.s. representatives pramila jayapal (wa 07), rosa delauro (ct 03), and jan schakowsky (il 09) are leading 60 lawmakers in calling on the centers for medicare and medicaid services (cms) to enact urgent reforms to medicare advantage (ma) plans. unlike traditional medicare, ma plans are administered by private insurers and have been found to be fraught with waste, fraud, and abuse, often sacrificing patient outcomes for higher corporate profit. “corporate health insurers offering ma plans are harming vulnerable patients across the country and endangering the solvency of the medicare trust funds,” wrote the members. “supporters of ma claim the program reduces costs. unfortunately, the ma program has never saved the government money. other recent data has shown that the bottom 5 percent of ma plans are responsible for 10,000 preventable deaths every year.” the private insurance companies running ma plans mislead the public by claiming their plans save money and improve care. studies have found just the opposite: cms pays 6 percent more per enrollee than it would for traditional medicare coverage, wasting billions of dollars every year. despite these higher costs, insurers administering ma plans provide consistently worse coverage. as an example, it was recently found that patients covered by privatized ma programs are significantly more likely to die in the month following surgery for stomach, pancreatic, or liver cancer compared to those in traditional medicare. by strengthening traditional medicare and taking actions to protect beneficiaries from ma, cms could save hundreds of billions of taxpayer dollars annually, money that could in turn be used to decrease the cost of traditional medicare for seniors and people with disabilities. the members are calling on cms to: “for far too long, medicare advantage plans have been significantly overpaid with little to show for it,” said david lipschutz, associate director center for medicare advocacy. “at the same time, barriers to care that people face in traditional medicare are often exacerbated when one is in an ma plan. we urge policymakers to continue the steps that have recently been taken to start to address these problems.” “right now, the government cannot protect people from joining medicare advantage plans that endanger their health,” said diane archer president, just care usa. “and, medicare advantage is driving up medicare premiums by tens of billions of dollars a year and compromising the medicare trust fund. these proposed actions would go a long way towards keeping medicare strong and honoring medicare’s commitment to guaranteeing older americans and people with disabilities good affordable health care.” “as a physician, and especially as a gynecologic oncologist, i have personally seen the damage that corporate controlled medicare advantage plans can do to patient care,” said pnhp vice president dr. diljeet singh, m.d., drph. “narrow networks and onerous prior authorization requirements lead to needless patient suffering and damaging delays in treatment, all in the name of providing more dollars to insurance companies. this letter represents an important step in cracking down on these abuses, and strengthening traditional medicare to make sure it stays a viable option for our seniors and people with disabilities.” “many medicare advantage plans are bad actors who rake in profits by delaying and denying the care seniors and people with disabilities need, while overcharging the government to the tune of $140 billion a year,” said nancy altman, president of social security works. “those plans should be called medicare disadvantage! thank you to representatives jayapal, delauro, schakowsky, and all the signers of this letter for fighting to protect medicare beneficiaries and ensure that they get the high quality health care they’ve earned.” “the medicare advantage program was created 25 years ago with the promise that the private sector could reduce costs by better managing care. but instead, it has become a shameless profiteering scheme. through waste, fraud, and abuse of the rules, insurance corporations will be overpaid by taxpayers by at least $88 billion this year   all while wrongly restricting provider networks, and denying and delaying care for many older americans and people with disabilities” said dr. jamila headley, executive director of be a hero. “this letter prescribes urgent solutions to these pressing problems. most critical among them is the need to reclaim the billions of dollars being gouged from taxpayers by large insurance corporations and instead invest these precious resources into improving medicare and ensuring that this vital public program is there for generations to come” the letter was signed by alma adams (nc 12), becca balint (vt al), nanette barragán (ca 44), jamaal bowman (ny 16), cori bush (mo 01), salud carbajal (ca 24), greg casar (tx 35), kathy castor (fl 14), judy chu (ca 28), yvette clarke (ny 09), steve cohen (tn 09), danny k. davis (il 07), christopher deluzio (pa 17), mark desaulnier (ca 10), debbie dingell (mi 06), jesús “chuy” garcía (il 04), robert garcia (ca 42), sylvia garcia (tx 29), daniel goldman (ny 10), raúl grijalva (az 03), val hoyle (or 04), sheila jackson lee (tx 18), henry johnson (ga 04), robin kelly (il 02), ro khanna (ca 17), andy kim (nj 03), raja krishnamoorthi (il 08), barbara lee (ca 12), teresa leger fernandez (nm 03), betty mccollum (mn 04), james mcgovern (ma 02), grace meng (ny 06), kweisi mfume (md 07), jerrold nadler (ny 12), grace napolitano (ca 31), joe neguse (co 02), eleanor holmes norton (dc), alexandria ocasio cortez (ny 14), ilhan omar (mn 05), chellie pingree (me 01), mark pocan (wi 02), katie porter (ca 45), ayanna pressley (ma 07), delia ramirez (il 03), patrick ryan (ny 18), mary gay scanlon (pa 05), adam schiff (ca 30), mark takano (ca 39), shri thanedar (mi 13), bennie thompson (ms 02), rashida tlaib (mi 12), jill tokuda (hi 02), paul tonko (ny 20), david trone (md 06), nydia velázquez (ny 07), bonnie watson coleman (nj 12), and nikema williams (ga 05). it was also endorsed by the american college of radiology, be a hero, business leaders for health care transformation, california onecare, center for health and democracy, center for medicare advocacy, center for popular democracy action, citizen action of wisconsin, health care for all  california, health care now, indivisible, international association of aerospace workers and machinists   california conference, iowa citizens for community improvement, justcare usa, labor campaign for single payer, national health care for the homeless council, national union of healthcare workers, people’s action, the people’s lobby, physicians for a national health program, progressive democrats of america (pda), progressive maryland, public citizen, rights & democracy, social security works, and therapists for single payer. the full text of the letter can be found here. issues: health care washington, dc office 2346 rayburn house office building washington. dc 20515 phone: 202 225 3106 fax: 202 225 6197 seattle office 2033 6th ave., suite 1011 seattle, wa 98121 phone: 206 674 0040 fax: 771 200 5813

pekic / getty images medicare advantage (ma) plans are an increasingly popular alternative to original medicare. they cover everything original medicare does, plus usually prescription drugs and vision, hearing, or dental care all at a low cost. but they do have downsides. a medicare advantage plan limits your choice of providers and requires preauthorizations and specialist referrals for many types of care. original medicare provides good basic care, but it doesn't include drug coverage and there are premiums, deductibles, and copays or coinsurance you'll need to pay. medigap plans can cover some of those costs. comparing medicare advantage to original medicare can quickly become confusing. in short, original medicare with a medicare supplement (medigap) plan offers maximum flexibility and coverage but may cost more each month. medicare advantage may cost less monthly and has built in price breaks on annual costs, but may involve more hassles with preauthorization and provider network requirements. here’s a quick chart to break down the differences. original medicare allows you to see any doctor or go to any hospital accepting medicare, but you’ll pay 20% of every bill as coinsurance. the government provides part a and part b coverage, and you can buy a separate part d (drug coverage) plan from a health insurance company. most beneficiaries also buy a medigap plan, which helps pay expenses such as medicare’s 20% coinsurance. it can also help pay for foreign emergency coverage. however, medigap doesn’t offer dental, vision, and hearing coverage. medicare supplement plan g or n can offer good cost coverage for those on original medicare, noted diane omdahl, a wisconsin based nurse educator and cofounder of 65incorporated.com, which offers fee based medicare counseling. omdahl serves people who are getting ready to enroll in medicare and those hoping to make a medicare change. medicare advantage plans typically require you to visit providers within the plan’s network to get the lowest costs. you’ll likely find more doctors available to you with original medicare. but most medicare advantage plans offer extra benefits, such as vision, dental, or hearing coverage or a free fitness club membership. the plans also limit how much you’ll have to pay out of pocket in a given year, with maximum out of pocket limits. medicare advantage plans differ in coverage and costs, even those sponsored by the same insurance company. some plans even have $0 premiums or $0 deductibles, though all require you to still pay your part b premium. (medicare advantage plans are partially funded by medicare, which is why costs are so low.) finding the details requires combing through the fine print in your "evidence of coverage" document, which outlines exactly how your benefits work for each issue. although medicare advantage’s low or $0 premiums, extra benefits, and all inclusive nature may sound appealing, familiarize yourself with the downsides before enrolling. "most enrollees believe they can later easily get out of medicare advantage when they can't," said omdahl. if you try to switch from medicare advantage to original medicare with medigap during medicare open enrollment, you may find an unpleasant surprise. because your guaranteed issue period has passed, you'll have to undergo medical underwriting to get a medigap plan to help cover extra expenses. "i can't tell you how many people call us at open enrollment and say nobody told them they'd have to go through underwriting or what that would entail, and say, 'if only i'd known,'" said omdahl. four states connecticut, maine, massachusetts, and new york offer underwriting free medigap enrollment outside the initial enrollment period. your medicare advantage plan may have more restrictions on your care that original medicare does not, including prior authorization and referral requirements. if you need a higher cost service, you’ll have to get your plan’s approval for coverage first. these services could include inpatient hospital stays or chemotherapy for cancer treatment. the goal is to manage healthcare costs by preventing unnecessary services. preauthorizations often include vague terms such as "not medically necessary," omdahl said. this catch all term could mean dozens of things it's the wrong service, the diagnosis doesn't support the service, or the frequency of visits is inappropriate, for example. original medicare has few prior authorization requirements, which are mainly limited to mobility devices and surgeries that could be classified as either cosmetic or not medically necessary. according to a kff study, insurers denied 7.4% of medicare advantage prior authorization requests in 2022, a larger share than in previous years. only around 10% of those denials were appealed. but of those that were, 83% had the denial overturned. this could indicate a potential headache for even the most tenacious ma enrollees a system of annoying hoop jumping. some plans are more likely to require preauthorization or overturned denials. according to the same kff study, humana had the most preauthorization requests per person and kaiser permanente had the fewest. humana also had the lowest success rate for overturning a denial. omdahl had low hopes for new rules around preauthorizations. in 2025, medicare advantage plans must evaluate how prior authorization policies impact certain at risk populations and publicly display analysis results on their websites. then starting in january 2026, insurers must respond to prior authorization requests in seven calendar days (shortened from 14) for standard cases and 72 hours for urgent cases. "i don't think it's going to fix a darn thing," she said. you'll likely get denials faster, with more specifics on why the denial occurred, but the 2026 timelines for appeal are lacking. "if you're diagnosed with cancer, the new rule could still leave you waiting 72 hours for expedited determination and seven days for standard determination for prior authorization and end up waiting months in appeals," said omdahl. with medicare, you can see any provider who accepts medicare assignment. that’s 98% of providers, according to the centers for medicare & medicaid services (cms). on the other hand, with medicare advantage, you’ll have a more limited set of providers to choose from. if you opt for an hmo plan, you’ll only be covered if you see in network doctors (except in emergencies). a ppo will give you the option of seeking care out of network, but you’ll pay more for those services. according to research from kff, these networks can vary widely. some narrower networks cover less than 30% of a county’s physicians. people who live in rural areas may have a harder time finding providers. if you're traveling, know that doctors aren't under obligation to see ma patients in a network the doctor doesn't contract with. so, you may see a doctor, but you'll pay out of pocket if the doctor doesn't work with your plan. "many people didn't realize it was an issue until they got a bill," omdahl said. while ma plans can’t charge you more than 20% for in network services, there are no limits on out of network cost sharing. as an example, a kff study found that over a third of ma plan enrollees with out of network coverage are charged between 30% and 100% for part b medications (such as chemotherapy drugs) if administered by an out of network provider. due to the network limitations, you don’t have the same cost coverage if you need to see a specialist who isn’t covered by your plan. you also may have a harder time traveling outside your plan’s service area if you’re a snowbird who travels to florida every year, your care may not be covered. plans may only allow you to be seen by a specialist with a referral, limiting your ability to easily self refer for a second or third opinion. medicare advantage plans are also constantly in flux. "now some are pulling out of counties, leaving people scurrying during open enrollment," said omdahl. “you’ll notice that your drug costs and the formulary can change throughout the year, as could your provider network," said omdahl. "the plan must notify you about the changes." be sure to read any notice your plan sends to learn how to find a new provider or plan. some changes may allow you to qualify for a special enrollment period. medicare advantage benefits can sound appealing on brochures or tv commercials. "the plans say 'free dental, free vision,' but don't always explain the limits well," said omdahl, pointing to the average vision coverage limit of $160. this price is much less than what glasses cost. most dental plan enrollees face dollar limits on how much care is covered in a year, and most are in plans with a maximum cap of $1,000 or less, the kaiser family foundation noted. some are even in plans with caps as low as $100 to $500. according to the same report, it’s less common to find a plan that covers root canals or dentures. fitness benefits can come with restrictions, too. omdahl noted the recent example of a fitness chain that only allows seniors with medicare advantage plans to visit during certain hours. "with benefits, it’s unfortunate that there are so many choices that change every year. it's overwhelming to understand all the rules up front," she said plus grasp how the rules might change or apply to you. while choice is typically a good thing, 98% of medicare beneficiaries will have 10 or more medical advantage health plans available in their area in 2025, including special needs plans (snps), according to a survey by cms. the selection of other plans per county also remains robust, with an average of 34 non snp ma plans offering prescription drug coverage and 65 plans offering it across all ma plans (including snps). "it takes time and can be overwhelming" to search for a good plan, omdahl said. the medicare plan finder lists advantage plans in order of lowest drug costs. then, it provides more details about each plan and a link to its website. you must then go to the plan site to ensure your doctor is within the network. this is great if you love comparison shopping, but it can be challenging to sift through and read all the fine print outlined above. medigap helps protect you from unexpected original medicare expenses but does come with an additional premium along with premiums you’ll pay for part b, and part d if you choose to buy drug coverage. if you can’t afford medigap coverage, a medicare advantage plan might be a good fit. that's particularly true if you missed your enrollment window to sign up for a medigap plan and can no longer qualify for or afford a medigap plan without medical underwriting. if you don’t use healthcare services regularly, you could get a $0 premium plan, stash your monthly savings in an interest bearing account and allow them to grow, earning returns for future medical costs. however, note that you no longer qualify to make health savings account (hsa) contributions after you enroll in medicare, so you’ll need to use a high yield savings account or some other savings vehicle. medicare advantage may be a good fit for those with a monetary inheritance and no known family history of chronic conditions. you may be able to stash away savings on premiums and have money to cover costs up to the out of pocket maximum if the unexpected should strike. "many people say, 'i want a lower premium, i never have medical issues and can afford the out of pocket maximum,'' said omdahl “if they get sick, they most likely will hit the maximum limit." conversely, if you have a chronic health condition (such as diabetes), you may qualify for a tailored chronic condition snp (c snp) medicare advantage plan with more robust benefits, such as transportation and meal service. there are currently 15 qualifying chronic conditions, including chronic lung disorders, mental health conditions, diabetes, and chronic heart failure. ma can also be a good fit if your preferred doctor, pharmacy, and hospital is within an existing medicare advantage network and you don’t plan to travel much within the u.s. during retirement. some ma plans offer more robust, broader in network coverage, the kff study on robust plans noted, covering up to 70% of a county’s physicians. finding these plans may take some research. medicare advantage’s extra coverages such as dental, vision, gym membership, and other coverage attract many sign ups, too. just ensure you understand the limitations. if you have the means and time to shop for part d and a medigap plan (assuming you want this coverage), you may find more flexibility and cost coverage. medicare advantage may not be a good fit for you if you: switching back to original medicare comes with some important caveats, depending on how long it’s been since you were in original medicare. if it’s been 12 or fewer months since you started with medicare advantage, you can switch back to your medigap plan if it’s still available. but if it’s been longer or you never signed up for a medigap plan, you may not qualify for one or will need to pay more. some states offer the opportunity to enroll in medigap at any time. preauthorization, or prior authorization, is your medicare advantage plan's decision on covering your care. in short, your health provider submits information in advance to support a service, treatment, prescription, or equipment to increase the likelihood that the plan pays your claim. your medicare advantage plan then decides whether that request meets the “medically necessary” requirement. it may not provide approval in some cases such as if you would like to take ozempic for weight loss. you can appeal the decision if your prior authorization is denied. insurance companies can profit from medicare advantage plans, although the plans aren’t necessarily always profitable for every company. in general, these plans encourage enrollment through extra benefits and maximum out of pocket limits that original medicare doesn’t offer. the average medicare advantage premium is estimated to be $17 in 2025. however, don’t forget that you’ll also likely pay the part b premium and out of pocket costs for deductibles, copays, and increased costs for any out of network care you get. these costs vary by plan. there’s also a certain cost for your time involved in preauthorization requests. it’s easier to understand the maximum you’d spend per year by reviewing the maximum out of pocket (moop) limit your plan lists. original medicare’s costs include monthly premiums and out of pocket costs such as deductibles and copays or coinsurance. ideally, your original medicare plan would involve buying part a, part b, part d, and a medigap plan. let’s consider an estimate. every month, you’d pay around $0 for part a, $175 for part b, $42 for part d (the average for standalone part d plans), and around $300 per month for a medigap plan’s costs. that comes to $531 per month for a fully loaded original medicare plan. your costs may be higher or lower depending on your chosen medigap and part d plans, and whether your income requires you to pay an extra fee on top of your part b premium. do your research before you buy an ma plan. "one of the biggest disadvantages is when people get into a medicare advantage plan at age 65 for free benefits like dental cleanings and free glasses and have no health problems," said omdahl. "but the plan is supposed to take care of big medical issues at age 75 and 80, too, and people are surprised by their coverage later on." medicare.gov. "compare original medicare & medicare advantage." medicare.gov. "doctor & other health care provider services." kff. "2025 medicare parts a & b premiums and deductibles." the commonwealth fund. "medicare advantage: a policy primer." center for retirement research at boston college. "medigap and the one way street problem." kff. “use of prior authorization in medicare advantage exceeded 46 million requests in 2022.” centers for medicare and medicaid services. “cms finalizes rule to expand access to health information and improve the prior authorization process.” centers for medicare and medicaid services. “annual medicare participation announcement.” kff. “medicare advantage: how robust are plans’ physician networks?” kff. “medicare part b drugs: cost implications for beneficiaries in traditional medicare and medicare advantage.” kff. “medicare and dental coverage: a closer look.” u.s. centers for medicare & medicaid services. "medicare advantage and medicare prescription drug programs to remain stable as cms implements improvements to the programs in 2025." medicare.gov. “explore your medicare coverage options.”
supported by the new old age medicare advantage plans say it reduces waste and inappropriate care. critics say it often restricts coverage unnecessarily. by paula span slowly but steadily, marlene nathanson was recovering. she had suffered a stroke in november 2022 at her home in minneapolis and spent a week in a hospital; afterward, when she arrived at episcopal homes in st. paul for rehabilitation, she couldn’t walk. weakness in her right arm and hand left her unable to feed herself, and her speech remained somewhat garbled. but over three weeks of physical, occupational and speech therapy, “she was making good progress,” her husband, iric nathanson, said. “her therapists were very encouraging.” ms. nathanson, then 85, had begun to get around using a walker. her arm was growing stronger and her speech had nearly returned to normal. then, on a wednesday afternoon, one of her therapists told the nathansons that their medicare advantage plan had refused a request to cover further treatment. “she has to leave our facility by friday,” the therapist said, apologetically. mr. nathanson, then 82, felt anxious and angry. he didn’t see how he could arrange for home care aides and equipment in 48 hours. besides, he said, “it didn’t seem right that the therapists and professionals couldn’t determine the course of her care” and had to yield to an insurance company’s dictates. “but apparently it happens a lot.” it does. traditional medicare rarely requires so called prior authorization for services. but virtually all medicare advantage plans invoke it before agreeing to cover certain services, particularly those carrying high price tags, such as chemotherapy, hospital stays, nursing home care and home health. “most people come across this at some point if they stay in a medicare advantage plan,” said jeannie fuglesten biniek, associate director of the program on medicare policy at kff, the nonprofit health policy research organization. after years of steep growth, more than half of medicare beneficiaries are now enrolled in advantage plans, which are administered by private insurance companies.

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