Prior authorization is one of the most significant — and most frustrating — differences between Medicare Advantage and Original Medicare. Understanding how prior authorization works in Florida can help you choose the right plan and navigate the system when you need care.

What Is Prior Authorization?

Prior authorization (PA) is a requirement by Medicare Advantage plans that your doctor obtain approval before certain medical services, procedures, or medications are covered. The plan reviews the request and determines whether the service is medically necessary according to its criteria. If approved, the service is covered. If denied, you must appeal or pay out of pocket.

Original Medicare vs Medicare Advantage

Original Medicare does not require prior authorization for most services. If your doctor orders a service that Medicare covers, Medicare pays. Medicare Advantage plans, by contrast, can require prior authorization for a wide range of services including specialist visits, imaging (MRIs, CT scans), surgeries, home health services, and prescription drugs.

The Scope of Prior Authorization in Florida

A 2022 HHS Office of Inspector General report found that Medicare Advantage plans denied 13% of prior authorization requests that met Medicare coverage criteria. In Florida, prior authorization denials have been a significant source of beneficiary complaints, particularly for cancer treatments, cardiac procedures, and post-acute care.

How to Appeal a Prior Authorization Denial

If your prior authorization request is denied, you have the right to appeal. The appeals process has five levels: redetermination by the plan, reconsideration by an independent review entity, ALJ hearing, Medicare Appeals Council review, and federal court review. Most successful appeals are resolved at the first or second level.

Request an expedited appeal if your condition is urgent. Plans must respond to expedited appeals within 72 hours.

Prior Authorization and Medigap

Medigap plans do not require prior authorization. If Original Medicare covers a service, your Medigap plan pays its share automatically. This is one of the most significant practical advantages of Medigap over Medicare Advantage for seniors with complex health needs.

Call (435) 612-1009 to discuss whether a Medigap plan might better serve your healthcare needs.