If I’m in a Medicare Advantage plan, will I still need prior authorization for procedures next year?

Question

Gary Church · Accepted Answer

Here's a question: If I'm on a Medicare Advantage plan, do I still need authorization for a procedure next year? The problem with next year's Medicare Advantage plans is they go for a calendar year, from January 1st to December 31st. In that current year, whatever authorizations you're looking at for the next year, you're just gonna have to wait till that calendar year starts.

But on a Medicare Advantage plan, for all intents and purposes, you have to get authorization from your carrier in reference to getting a procedure. So again, there are limitations to Medicare Advantage. But I highly recommend that you sit down with a licensed Medicare agent or your agent who helps you with Medicare to figure out what options you have and whether or not you can make any changes.

So hopefully that answers your question.

Mark Bilgere · Answer

Medicare Advantage plans will still require Prior Authorizations for certain procedures in 2026. Although CMS is trying to enact some new rules that shorten the decision period it has not eliminated the process altogether.

Answered by Mark Bilgere on November 10, 2025

Broker Licensed in TX, AR, IN & LA, MN, NE & OK

Answered by Mark Bilgere Medicare Insurance Agent

George Ibanez · Answer

All advantage plans require pre-authorizations for procedures, and the only way to avoid that is to switch to a Medicare supplement plan.

For hel,p contact George Ibanez.

Lauren Fodde · Answer

Yes, you will still need prior authorization for procedures next year. 

With any Medicare advantage plan, you will need prior authorization.

James Carlson · Answer

Yes.  One type of plan, a Medicare Supplement does not require a referral.  Most Advantage plans require referrals.

Robert Pennington · Answer

Yes. Most of the time this is handled by your PCP. Medicare Advantage enrollees are required to obtain prior authorization for some services, such as inpatient hospital stays, skilled nursing facility stays, and chemotherapy. This process is to ensure services are medically necessary and to control costs.

Answered by Robert Pennington on May 1, 2026

Broker Licensed in NC, GA, SC & VA

Answered by Robert Pennington Medicare Insurance Agent

Jeffrey Jon · Answer

If your current MAPD plan requires prior authorization this year, it does not mean the same for next year. Each year changes. They may require prior authorization or not.

Bob Thompson · Answer

Yes, if you're in a Medicare Advantage (MA) plan, you may still need prior authorization (PA) for certain procedures, tests, or treatments next year. Medicare Advantage plans are offered by private insurers and they often have specific rules and requirements for covered services, which may include prior authorization.
The need for prior authorization depends on the specific plan and the type of service you're seeking. For example, some plans might require prior authorization for elective surgeries, expensive diagnostic tests, certain medications, or specialty care. The requirements and the process for getting approval may vary from one insurer to another and from one type of care to another.
To know exactly what will require prior authorization next year:
Review your plan’s formulary or benefits guide: This should be updated for the new year, and it will list which services require prior authorization.
Talk to your insurer: If you’re uncertain about any upcoming procedures or treatments, it’s always a good idea to contact your Medicare Advantage plan’s customer service to confirm.
Discuss with your doctor: Your healthcare provider can often help navigate the prior authorization process, as they will be familiar with which services tend to require it and can submit the necessary paperwork on your behalf.
It’s good to plan ahead because prior authorization can sometimes take time to process, and delays could impact when you can get a procedure or treatment.

Albert Ojeda · Answer

You will likely still need prior authorization for many procedures next year (2026) and possibly in the years ahead If you’re enrolled in a Medicare Advantage plan. MA plans almost always require prior authorization for certain services before they’ll agree to cover them (especially higher-cost items like hospital stays, chemotherapy, durable medical equipment, etc.). This requirement will continue into 2026 and likely future years because Medicare Advantage insurers use prior authorization as a tool to manage costs and utilization. Starting in 2026, new federal rules are meant to make prior authorization easier by setting firm deadlines for insurer decisions and requiring clearer explanations when coverage is denied.

Answered by Albert Ojeda on February 9, 2026

Broker Licensed in CA, AZ, FL, NV & TX

Answered by Albert Ojeda Medicare Insurance Agent

Jim Tretola · Answer

It all depends upon the Plan, but generally yes, you will need prior authorization. Medicare Advantage Plans are part of managed healthcare, and one goal is to control costs. If this is not something you want, and you can afford it, you might want to consider a Medigap Plan.

Answered by Jim Tretola on November 10, 2025

Broker Licensed in NJ, CA, CT & 6 other states

Answered by Jim Tretola Medicare Insurance Agent

William Brobson · Answer

If the plan you are currently in requires prior authorization for procedures then more than likely yes you will need prior authorization.

Ron Hamilton · Answer

The short answer is Yes.  It's a good idea to make sure that the procedure you are considering is covered by your plan.  A Prior Authorization also can let you know what to expect financially.

Hope this helps.  Thanks for reaching out.

Stephen Merrill · Answer

The basic architecture of the Health Maintenance Organization will still require referrals and prior authorizations for medical procedures.

Andrew Kramer · Answer

You will need prior auth's no matter what plan you are on, Advantage HMO, PPO or original Medicare! Think about it... could you walk into an imaging center and ask to get an MRI and have your Advantage plan pay for it? You have always needed an auth. What you don't need on a PPO is a referral to see a specialist, but that's it.

Answered by Andrew Kramer on November 14, 2025

Agent Licensed in FL

Answered by Andrew Kramer Medicare Insurance Agent

Mark Boone · Answer

Medicare Advantage plans are a form of managed care, and prior authorization is used to manage costs by ensuring services are medically necessary before they are approved

Carol Conner · Answer

Medicare advantage different than a Medigap supplement because Medicare advantage either has HMO or PPOs and yes you have to have referrals to go to a specialist if you’re on a Medigap supplement then you’re free to go to any doctor anywhere any time

Answered by Carol Conner on November 23, 2025

Broker Licensed in TX

Answered by Carol Conner Medicare Insurance Agent

Mel Stevens · Answer

Yes indeed.  Prior authorization is not going away any time soon. In fact, there's chatter of insurance companies also implementing prior authorization for supplement plans as well.

Adam Ernst · Answer

It depends on if you are in a PPO or HMO. You would want to see what the coverage will be. If it is medically necessary, then yes you will need authorization and will more than likely be fine. The costs will definitely be an important question for the carrier/agent. They should be able to tell you the exact costs or you can look in your Summary of Benefits from your MA plan.

Answered by Adam Ernst on January 15, 2026

Agent Licensed in NC, SC & TN

Answered by Adam Ernst Medicare Insurance Agent

Angelina Watkins · Answer

Prior authorization requirements are sent by your Medicare Advantage carrier. Prior authorizations can vary by services and carrier. It is always best to call your carrier customer service to very requirements for your particular need.

Answered by Angelina Watkins on December 15, 2025

Agent Licensed in OH, FL, GA & 5 other states

Answered by Angelina Watkins Medicare Insurance Agent

Gene Page · Answer

Every plan has its own rules. Check your plan documents. 

Most HMO plans are going to be more restrictive. 

PPO plans, PFFS plans, and HSA plans will give you more latitude, but could have higher cost sharing to accommodate those additional choices. 

Medigap plans (also known as Medicare Supplements) will allow you the most freedom of choice. 

Medicare (CMS) may restrict certain procedures.

David Fiveash · Answer

Yes, 
usually you need to because they all have short expirations dates 
Prior authorizations are made only for a certain period time.
If you change you will need new prior authorizations

Mark Mullinax · Answer

Not all plans require prior authorization, if you speak to you agent they should be able to help you find a plan that does not require prior authorization. We are eager to help you find the best coverage as well as attend to your needs regarding your plan.

Answered by Mark Mullinax on November 10, 2025

Agent Licensed in GA, AL, FL & NC, SC, TN & TX

Answered by Mark Mullinax Medicare Insurance Agent

Sonia Heredia · Answer

Yes it is but there is a mandatory approval for many services. Such as MRI, different types of scans.

If I’m in a Medicare Advantage plan, will I still need prior authorization for procedures next year?

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