Fewer PA Requirements Among System-Affiliated MA Health Plans

Key Takeaways:

• In a study assessing prior authorization (PA) requirements among Medicare Advantage (MA) plans, health system affiliation was associated with less restrictive PA policies.
• System-affiliated plans required PA for fewer service categories than unaffiliated plans, with fewer beneficiaries being subject to PA requirements.
• Differences in PA policy were greatest in behavioral and mental health services and dialysis, areas in which restrictive PA policies may disrupt continuity of care and increase administrative burden.

MA enrollment has grown substantially, with 54% of all Medicare beneficiaries enrolled in MA plans in 2025. This growth has raised concerns about patient access and administrative burden because PA requirements are more prevalent in MA than in traditional Medicare or Medicaid.

Health system affiliation may also influence PA policies, potentially contributing to differences in utilization management and approval processes.

Study Methods and Outcomes

Using data taken from the Agency for Healthcare Research and Quality (AHRQ) Compendium of US Health Systems, researchers compared PA policies between system-affiliated and unaffiliated MA plans from 2016 through 2023.

Overall, the study analyzed 6480 MA health plans across 23 service categories.

Trends in PA Policies

System-affiliated plans imposed fewer PA requirements compared to plans not affiliated with a health system. In 2023, system-affiliated plans had a PA rate that was 31 percentage points lower than that of unaffiliated plans. PA was required for 51% of service categories among system-affiliated plans compared with 82% among unaffiliated plans.

Differences were most pronounced for behavioral and mental health services and dialysis. PA rates among system-affiliated plans were 55 to 59 percentage points lower for behavioral and mental health services and 52 percentage points lower for dialysis than rates among unaffiliated plans. Approximately one-third of beneficiaries enrolled in system-affiliated plans were subject to PA requirements for these services compared with nearly all beneficiaries enrolled in unaffiliated plans.

These differences may reflect the complex and ongoing nature of care for these conditions. Behavioral and mental health and dialysis services often require frequent interactions with providers, and restrictive PA policies may lead to delays in care and increase administrative burden, disrupting care continuity.

Implications for Managed Care

These findings suggest that health system affiliation may be a significant factor associated with differences in PA regulation requirements among MA plans and may provide insights for future utilization management and policy reform.

The authors noted, “These findings suggest that health system affiliation is associated with a distinct approach to utilization management, consistent with theoretical predictions that vertically integrated insurers rely less on PA, as financial incentives are partially internalized and organizational structures provide alternative means of cost control.”

Reference

Shin E. Health system integration and prior authorization in Medicare Advantage. Health Serv Res. 2026;61(3):e70137. doi:10.1111/1475-6773.70137