Social Vulnerability Associated With Restrictive PA Policies Among MA Beneficiaries
Key Takeaways:
- Across Medicare Advantage (MA) plans, counties higher on the Social Vulnerability Index (SVI) had a higher rate of prior authorizations (PA) than low SVI counties.
- The socioeconomic domain and psychiatric services had the greatest difference across SVI deciles, with more socially vulnerable beneficiaries having higher PA rates.
- High SVI counties had less permissive and more restrictive PA policies compared to low SVI counties.
While MA offers extra benefits, lower premiums, and out-of-pocket spending caps, the strategies it employs to control costs, specifically PAs, may increase health care disparities. Most MA plans have a PA requirement, which can create access barriers and delay care.
Considering how social vulnerability is linked to various care disparities and worse health outcomes, researchers observed the relationship between county-level social vulnerability and PA policies for MA beneficiaries.
Study Methods and Outcomes
Using Centers for Medicare & Medicaid Services (CMS) MA plan benefits data, researchers conducted a cross-sectional analysis of 2945 US counties in 2022.
The primary outcome was the average PA rate for Medicare-covered services across all MA plans. Secondary outcomes included the distribution of MA plans in each county, the restrictiveness of PA policies, and average monthly premiums.
Social Vulnerability Associated With Restrictive PA Policies
Higher SVI counties (deciles 8-10) had a higher PA rate compared to lower SVI counties (deciles 1-3), 92% vs 87%, respectively.
Socioeconomic vulnerability had the greatest increase in PA rates, with the lowest decile having a rate of 86.3% and the tenth decile having a rate of 93.5%. In the same domain, high SVI counties had lower monthly premiums compared to low SVI counties, $9 vs $29, respectively.
When analyzed across service categories, psychiatric services had the largest difference in PA rates, 77% vs 89%, respectively.
While the number of MA plans was similar across SVI deciles, more vulnerable counties had more restrictive PA policies than less vulnerable counties. High SVI counties had 4.9 fewer permissive plans and 3.5 more restrictive plans than low SVI counties.
Implications for Managed Care
These findings illustrate the association between social vulnerability and restrictive PA policies among MA beneficiaries, with the socioeconomic domain and psychiatric services having the greatest disparities. Therefore, beneficiaries in more vulnerable counties may face higher administrative burden and an increased risk of delayed care, which can lead to worse health outcomes.
The authors noted that high SVI counties had lower monthly premiums, suggesting that beneficiaries may face a trade-off when choosing a health plan.
The authors said, “Our findings suggest CMS should monitor not only overall PA burden but also whether requirements disproportionately affect enrollees in socially vulnerable areas. Policy makers could also consider incorporating social vulnerability into MA payment policy.”
Reference
Shin E, Lei L. Prior authorization requirements in Medicare Advantage and county social vulnerability. Am J Managed Care. 2026;32(8):444-451. doi:10.37765/ajmc.2026.90000
