Medicare Benefit plans denied 3.4 million prior authorization requests for well being care companies in complete or partly in 2022, or 7.4% of the 46.2 million requests submitted on behalf of enrollees that 12 months, in line with a brand new KFF evaluation of federal knowledge.
That was the next share of denials than lately. The share of all prior authorization requests denied by Medicare Benefit plans elevated from 5.7% in 2019, 5.6% in 2020 and 5.8% in 2021.
Prior authorization is meant to make sure that well being care companies are medically needed by requiring suppliers to acquire approval earlier than a service or different profit is roofed. Whereas prior authorization has lengthy been used to comprise spending and stop individuals from receiving pointless or low-value companies, it additionally has been topic to criticism that it could create obstacles to receiving needed care. (Conventional Medicare doesn’t require prior authorization aside from a restricted set of companies.)
Prior authorization practices have attracted the eye of the Biden Administration and lawmakers in Congress. The administration just lately finalized guidelines to extend the timeliness and transparency of prior authorization choices and require Medicare Benefit plans to judge the impact of prior authorization insurance policies on individuals with sure social threat components. Lawmakers have launched payments to codify many of those modifications into regulation.
Different key takeaways from the KFF evaluation embrace:
Only one in 10 (9.9%) prior authorization requests that had been denied had been appealed in 2022. That represents a rise since 2019, when 7.5% of denied prior authorization requests had been appealed.
The overwhelming majority of appeals (83.2%) in 2022 resulted in overturning the preliminary resolution, much like the shares overturned and in annually between 2019 and 2021.
Sufferers might have completely different experiences relying on the Medicare Benefit plan wherein they’re enrolled. The amount of prior authorization determinations different throughout Medicare Benefit insurers, as did the share of requests that had been denied, the share of denials that had been appealed, and the share of selections that had been overturned upon enchantment.
Two different KFF analyses launched as we speak additionally study the most recent knowledge about Medicare Benefit.
The primary supplies info and developments about present Medicare Benefit enrollment, by plan kind and agency, and by state and county. It exhibits that in 2024, greater than half (54%) of eligible Medicare beneficiaries are enrolled in Medicare Benefit. The share of beneficiaries in Medicare Benefit plans varies throughout states starting from 2% in Alaska to 63% in Alabama, Connecticut and Michigan. Medicare Benefit enrollment is extremely concentrated amongst a small variety of corporations, with UnitedHealthcare and Humana accounting for practically half (47%) of all Medicare Benefit enrollment nationwide.
The second companion evaluation describes Medicare Benefit premiums, out-of-pocket limits, supplemental advantages provided, and prior authorization necessities. In 2024, three quarters (75%) of enrollees in particular person Medicare Benefit plans with prescription drug protection pay no premium apart from the Medicare Half B premium, which is an enormous promoting level for a lot of beneficiaries. Most Medicare Benefit enrollees are in plans that provide supplemental advantages not lined by conventional Medicare, akin to imaginative and prescient, listening to and dental. And practically all Medicare Benefit enrollees (99%) are in plans that require prior authorization for some companies.
