Key Points
Many seniors rely on Medicare to provide them with essential healthcare coverage. Unfortunately, over 6 million of those seniors now will be impacted by a new rule that has advocates very concerned about its impact on care.
Here’s the rule change that’s affecting Medicare beneficiaries, along with some details on why seniors may be adversely impacted by the shift.
This change in Medicare rules has advocates worried
The Medicare change taking effect in January will impact 6.4 million seniors who live in New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington state and have traditional Medicare coverage. It will not impact seniors who have a Medicare Advantage plan.
Beginning this month, Medicare beneficiaries in these states will need to get prior approval for 17 different Medicare procedures. Prior approval, or preauthorization, means that the doctor requests coverage for the procedure before performing it in order for insurance to cover it.
Medicare has traditionally required prior approval in very limited circumstances. In fact, in 2023, around one prior authorization review was submitted for every 100 traditional beneficiaries. However, this is changing as a result of a new pilot program that requires preauthorization for medical procedures that are often found to be wasteful.
Advocates warn about the impact on patient care
While the goal of requiring preauthorizations is supposedly to cut down on wasteful care, the reality is that many advocates are concerned that it’s simply going to make getting essential care more difficult, even when people really need it.
“We already know that prior authorization creates major burdens and delays for patients and providers, and expanding it to Traditional Medicare will just force seniors to wait longer and navigate mountains of paperwork to get the care their doctor says they need,” says Senator Patty Murray of Washington in a statement. “Make no mistake: This is a backdoor effort to privatize Medicare and cut benefits.”
Murray isn’t alone in her concern, as the heads of medical associations in all six participating states sent a memo in November to Dr. Mehmet Oz, the CMS administrator, stating, “We believe the current design of this pilot risks unintended consequences, including delayed care, reduced access, and increased burdens on both patients and physicians.”
Despite these concerns, the requirement is still in effect, which means that retirees who live in these six locations may soon face harsh restrictions and may not be able to get all of their desired care covered. Those who want treatment that’s not approved during the authorization process may have to forgo the treatment they were hoping to get or have to pay for it out of pocket.
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