Have you heard about the pilot program slated to begin in January 2026, requiring prior authorization in six states for certain Medicare procedures for those enrolled in Original Medicare only?
The states — New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington — will apply prior authorization evaluations to more than a dozen services per CMS. And this test will not apply to those with a Medicare Advantage plan.
This model is being tested to reduce waste, fraud, and abuse. Waste in healthcare represents up to 25% of healthcare spending in the United States. The Medicare Payment Advisory Commission estimates that up to $5.8 billion in Medicare spending in 2022 alone was spent on services with what they describe as “minimal benefit”.
Determining if a treatment or service provides minimal benefit requires a comprehensive assessment of its clinical appropriateness, scientific evidence, cost-effectiveness, and alignment with patient values and preferences.
Specific services that will require prior authorization in the six states for Original Medicare plan holders are skin and tissue substitutes, electrical nerve stimulator implants, and knee arthroscopy. It is reported that emergency services or treatments would pose a significant risk for patients if delayed.
CMS will contract with specific private companies that will operate in assigned geographic regions and must have clinicians with appropriate expertise to conduct medical reviews and validate coverage determinations. Under the model, providers and suppliers in the assigned regions will have the choice of submitting prior authorization requests for selected items and services, or their claim will be subject to pre-payment medical review.
They report that technology will support the review process, with final decisions that a request for one of the selected services does not meet Medicare coverage requirements will be made by licensed clinicians. The companies contracting to do the review process will receive payments when they reduce costs in Original Medicare.
Image by Pete Linforth from Pixabay
Prior Authorization Across Plans
Requiring prior authorization for certain services and medications is not unusual in private health plans or for those on Medicare Advantage plans. After some checking, here are some Examples of Services Often Requiring Prior Authorization:
Outpatient Hospital Services: Some outpatient procedures and treatments.
Specialty Medications: High-cost drugs, especially those used to treat complex conditions.
Surgical Procedures: Inpatient and outpatient surgeries.
Imaging Services: MRI, CT scans, and other advanced imaging.
Durable Medical Equipment: Certain medical devices or equipment.
Image by an_photos from Pixabay
What to Do
- Check with your plan: It’s crucial to check your specific health plan’s member handbook or website to understand what services require prior authorization, says Healthinsurance.org.
- Communicate with your doctor: Discuss the plan’s prior authorization requirements with your doctor or healthcare provider to ensure proper procedures are followed.
- Understand your responsibility: Even with prior authorization, you may still be responsible for copays, deductibles, or coinsurance as outlined in your plan.
From personal experience, having an insurance broker/agent helps tremendously when making your healthcare plan decisions. They are the ones who are “in the know” and can work with you to determine your options.
This year has taught us to be ready for changes. I know some terrific professionals who specialize in insurance if you’d like a recommendation. Send me an Email or Book a Time with Lynn if you have any questions or would like to connect via Zoom to discuss.
For additional information about my work, check out @ The Living Planner or @ The Living Planner. If you’re up for pre-planning, my book is a resource for you. The Living Planner What to Prepare Now While You Are Living © Check it out HERE.
Quote for the week: “The only way to make sense out of change is to plunge into it, move with it, and join the dance.” Alan Watts
Keep on rolling 🌞Lynn
#Can’tPredictCanPrepare #CareForPeopleCareForBusiness