Medicare Advantage costs and prior authorization rules continue to impede access to care. Anyone enrolled in a Medicare Advantage plan–Medicare coverage administered by a corporate health insurer–should be concerned about whether they will be able to get and afford the care they need if they get sick. Traditional Medicare provides coverage for care from almost any physician or hospital in the US without the need for prior authorization.
Jakob Emerson reports for Beckers Payer that typical deductibles for Medicare Advantage plans are now more than twice what they were in 2024. It’s fair to assume that they will continue to rise, given the Trump administration’s full court press on government spending. You’ll be fine in Medicare Advantage if you’re healthy, but you’ll likely be far better off in traditional Medicare if you want to ensure you’ll be able to afford and receive the care you need when you get sick.
Average Medicare Advantage deductibles were about $132 in 2024 and are now $315, according to an eHealth survey. That’s a 139 percent increase. Monthly premiums average just $5 a month this year, down from $9 in 2024. And, total out-of-pocket costs for covered in-network services can be as high as $9,350 this year, depending upon the Medicare Advantage plan.
Average Medicare Part D prescription drug coverage premiums are also up, from $29 to $36, about 25 percent.
Meanwhile, prior authorization rules remain another obstacle to care for Medicare Advantage enrollees, particularly those who need costly and complex care. Rylee Wilson reports for Beckers Payer that some states are looking into regulating insurers’ use of prior authorization. They are especially focused on insurers’ use of artificial intelligence or AI to determine whether a procedure should be covered and want a physician to oversee those decisions. (Could that simply mean a physician rubber-stamping them?)
Patients are currently suing UnitedHealth and Humana for using AI to deny rehab care in Medicare Advantage inappropriately. UnitedHealth spokespeople argue that they do not use AI exclusively to make coverage decisions. They might not, though having a provider oversee these decisions with financial and other incentives to approve them is no better than using AI exclusively.
Last year, the Centers for Medicare and Medicaid Services, CMS, which oversees Medicare, issued guidance on the use of AI in Medicare Advantage. CMS did not ban the use of AI or even restrict it. It simply said that the AI algorithm must comply with Medicare’s coverage requirements. Good luck enforcing that rule.
Dr. Mehmet Oz, who will head of CMS, once confirmed, believes in AI as a tool for expediting prior authorization decisions–seemingly, even though they can speed up inappropriate denials. However, Oz says that insurers should not use AI for more than 1,000 procedures.“I would argue that to use AI wisely, we would make a decision which is we’re only going to pre-authorize 1,000 procedures,” he said at a recent Senate hearing. Where he pulled the 1,000 number from is anyone’s guess.
Here’s more from Just Care:
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