One of the biggest frustrations I hear from people enrolled in Medicare Advantage plans is this:

“My doctor recommended the procedure, but the insurance company says I need prior authorization.”

If you’ve ever wondered why some Medicare plans require prior authorization while Original Medicare generally does not, you’re not alone.

Understanding this difference can help you choose the Medicare coverage that’s right for you.

What Is Prior Authorization?

Prior authorization is when an insurance company requires approval before certain medical services, tests, procedures, or medications will be covered.

Examples may include:

• MRI and CT scans
• Surgeries
• Certain specialist visits
• Physical therapy
• Durable medical equipment
• Some prescription medications

The goal is to ensure services are medically necessary before the insurance company agrees to pay.

Why Doesn’t Original Medicare Require Prior Authorizations?

Original Medicare was designed as a fee-for-service program.

In most cases:

• Your doctor recommends treatment.
• You receive the treatment.
• Medicare reviews the claim after it is submitted.

Rather than asking for permission before care is received, Medicare generally allows physicians to make treatment decisions and reviews medical necessity afterward.

This means that if Medicare covers the service and your doctor believes it is medically necessary, you can typically move forward without waiting for approval.

What About Medicare Advantage Plans?

Medicare Advantage plans are offered by private insurance companies that contract with Medicare.

These plans often use:

• Provider networks
• Referrals
• Prior authorizations
• Care management programs

As a result, certain services may require approval before treatment can be scheduled.

This doesn’t mean Medicare Advantage plans are bad. In fact, many people are very happy with their Medicare Advantage coverage.

However, it’s important to understand that these plans often have additional rules that do not exist under Original Medicare.

Do You Need Referrals With Original Medicare?

In most cases, no.

One of the benefits many retirees appreciate is the ability to see specialists without obtaining a referral from a primary care physician.

For example, if you want to schedule an appointment with:

• A cardiologist
• A dermatologist
• An orthopedic surgeon
• A neurologist

You can typically contact the specialist directly if they accept Medicare.

Many Medicare Advantage HMOs, on the other hand, may require referrals before specialist visits are covered.

What About Networks?

Another major difference is provider networks.

With Original Medicare and a Medicare Supplement plan, you can generally see any provider in the United States that accepts Medicare.

This can be especially valuable for:

• Snowbirds
• Frequent travelers
• People who live in multiple states
• Individuals seeking care from major medical centers

Many Medicare Advantage plans have local or regional provider networks that members must use for the lowest costs.

Are There Any Prior Authorizations Under Original Medicare?

Yes, but they are limited.

Certain services may require prior authorization, including some:

• Durable medical equipment
• Repetitive ambulance transportation
• Specialized outpatient services

However, compared to Medicare Advantage plans, prior authorization requirements under Original Medicare are relatively uncommon.

Which Option Is Better?

The answer depends on your personal preferences.

Some people prioritize:

• Lower monthly premiums
• Additional benefits
• Medicare Advantage plan features

Others prioritize:

• Freedom to choose providers
• Fewer prior authorizations
• No referrals
• Nationwide access to care

Neither option is right for everyone.

The key is understanding the tradeoffs before you enroll.

Final Thoughts

When comparing Medicare Supplement plans and Medicare Advantage plans, don’t focus only on premiums.

Ask questions such as:

• Will I need referrals?
• Are there provider networks?
• How often are prior authorizations required?
• Do I want more flexibility when seeking care?

These factors can have a major impact on your healthcare experience long after enrollment.

If you’re turning 65 or already on Medicare and would like help comparing your options, I’m happy to help you understand the differences and find a plan that fits your needs.

Tyler Haskell, CFP®
Professional Insurance Solutions

801-369-3090