Prior authorization means your Medicare Advantage plan may require approval before it will cover certain medical services, procedures, supplies or treatments.
Your doctor or other healthcare provider generally submits information to the plan showing why the care is medically necessary.
Beginning primarily in 2026, new CMS requirements have strengthened prior-authorization processes for Medicare Advantage and other affected payers, including faster decisions and requirements to provide specific reasons for denials. (CMS)
Your physician recommends a procedure, service, medication, test or medical item.
If authorization is required, the provider submits a request to your Medicare Advantage plan.
The plan evaluates the request using applicable coverage and medical-necessity criteria.
If approved, you proceed according to the authorization.
If denied, you and your healthcare provider may have options to submit additional information or appeal.
2026 Prior Authorization Changes
CMS rules that take effect primarily in 2026 require affected payers, including Medicare Advantage organizations, to improve prior authorization processes.
For applicable medical requests, the rules generally require decisions within:
72 hours — expedited/urgent requests
7 calendar days — standard requests
The payer must also give a specific reason for denying a prior authorization request. (CMS)
Continuity of Care
Existing Medicare Advantage rules also provide important protections when someone changes plans while undergoing treatment.
A new coordinated-care plan generally must provide a minimum 90-day transition period during which prior authorization can’t be required for an active course of treatment.
Approvals for a course of treatment must also remain valid for as long as medically reasonable and necessary under applicable criteria. (CMS)
Medicare Advantage Prior Authorization: What You Need to Know
Prior authorization is one of the most important differences people need to understand when comparing Medicare Advantage with Original Medicare.
When you’re healthy, it may seem like a technical issue.
It becomes much more important when you’re dealing with:
cancer treatment
major surgery
rehabilitation
advanced imaging
or another serious medical condition.
I don’t tell people Medicare Advantage is automatically bad because it uses prior authorization.
I tell them to understand who controls the approval process before they’re the person waiting for approval.
Medicare Advantage plans cover Medicare-covered cancer treatment, including qualifying chemotherapy, but plan networks, prior authorization rules and out-of-pocket costs can become especially important when someone has cancer.
Medicare’s Annual Enrollment Period, also commonly called Medicare Open Enrollment, runs, October 15 through December 7 each year.
