If you’ve ever been told by your doctor that a treatment or medication needs “prior authorization” before your insurance will cover it, you know how stressful and confusing that experience can be. For Washington State Medicare enrollees, this issue has become increasingly important in 2026—thanks to sweeping federal rule changes that affect how Medicare Advantage plans handle prior authorization requests.
Whether you’re already on Medicare, approaching 65, or helping a family member navigate their coverage, this guide breaks down what prior authorization means, how the new rules affect you, and what steps you can take to protect your care.
Prior authorization (PA) is a requirement from a health insurance plan that a doctor or healthcare provider must get approval before delivering a specific treatment, procedure, or prescription—or the plan won’t cover the cost.
Prior authorization is not required under Original Medicare (Parts A and B) for most services. However, it is commonly used by Medicare Advantage (Part C) plans, which are run by private insurers that contract with Medicare.
If you’re enrolled in a Medicare Advantage plan in Washington State, your plan may require prior authorization for:
The concern for many patients and physicians has been that prior authorization can delay or deny necessary care—sometimes with serious health consequences.
The Centers for Medicare & Medicaid Services (CMS) finalized a significant rule that began phasing in starting in 2024 and continues to take full effect in 2026. This rule places new obligations on Medicare Advantage plans to make the prior authorization process faster, more transparent, and less burdensome for patients and providers.
Faster decision timelines. Medicare Advantage plans must now respond to urgent prior authorization requests within 72 hours and non-urgent requests within 7 calendar days. Previously, delays stretched far longer in many cases.
Gold carding. Some insurers are now required or encouraged to exempt physicians with strong approval track records from the PA process for certain services—a practice known as “gold carding.”
Continuity of care protections. If you switch Medicare Advantage plans, the new plan must honor any previously approved prior authorization for at least 90 days, giving you time to transition without interruption.
Transparency requirements. Plans must publicly report their prior authorization approval and denial rates, giving consumers better information when comparing plans during open enrollment.
Expanded appeal rights. Patients denied prior authorization now have clearer paths to appeal, including expedited reviews for urgent medical situations.
These changes are enforced through CMS oversight and apply to all Medicare Advantage plans operating in Washington State.
Authoritative source: For the full details on these federal prior authorization rules, visit the official CMS Medicare Advantage Prior Authorization guidance.
For the most part, no. Original Medicare (Parts A and B) does not require prior authorization for the majority of covered services. If your doctor determines a service is medically necessary and it’s covered under Medicare’s guidelines, you can generally receive it without pre-approval.
There are a handful of limited exceptions—such as certain outpatient procedures under a specific CMS demonstration program—but they affect a small subset of services.
This is one reason some beneficiaries prefer Original Medicare paired with a Medigap (Medicare Supplement) policy: they have more flexibility to see any Medicare-participating provider with fewer administrative hurdles.
To understand how Original Medicare compares to Medicare Advantage in Washington, read our detailed guide: What Are the Different Parts of Medicare (A, B, C, D) in Washington?
Washington State has a competitive Medicare Advantage marketplace, with multiple insurers offering plans in the Tri-Cities, Seattle metro, Spokane, and surrounding regions. Each plan sets its own prior authorization policies—within the boundaries set by CMS.
This means two Medicare Advantage plans covering the same county may have very different prior authorization requirements. Plan A might require PA for an MRI; Plan B might not. Plan A might approve specialist visits quickly; Plan B might have a longer review process.
When comparing plans during Medicare Open Enrollment (October 15 – December 7), understanding a plan’s prior authorization practices is just as important as comparing premiums and deductibles.
When evaluating a Medicare Advantage plan, here are key questions to ask:
These questions are often best answered with help from a licensed Washington Medicare broker who knows the local plan landscape.
Prior authorization also applies to Medicare Part D prescription drug plans—both standalone Part D plans and the drug coverage built into Medicare Advantage.
Under Part D, plans use prior authorization to control costs and ensure drugs are prescribed appropriately. You may need PA for:
Step therapy is a related requirement where you must try a lower-cost drug first before the plan will approve a more expensive alternative. New CMS guidance has placed guardrails on step therapy for Medicare Advantage plans, but it still applies in many situations.
The 2026 Medicare Part D changes include important updates to prescription costs and coverage that interact directly with PA requirements.
Important resource: The Medicare Rights Center offers a free guide to understanding and appealing prior authorization denials at medicarerights.org.
A denial is not the end of the road. Under current CMS rules, Medicare Advantage enrollees in Washington have the right to appeal any prior authorization denial.
Before diving into the steps, it’s worth knowing that you are legally entitled to appeal any denial—and your doctor can (and should) support you through that process with documentation. Don’t assume a denial is final.
Step 1 – Request a Redetermination. Ask your plan to review the denial again. Your doctor may need to submit additional clinical documentation explaining why the service is medically necessary. You have 60 days from the denial notice.
Step 2 – Reconsideration by an Independent Review Entity (IRE). If the plan upholds the denial, an independent organization reviews your case. For urgent requests, this review must happen within 72 hours.
Step 3 – Administrative Law Judge (ALJ) Hearing. If you’re still denied and the amount in question meets a minimum threshold, you can request a hearing before an ALJ.
Step 4 – Medicare Appeals Council. Further appeals go to the Medicare Appeals Council within CMS.
Step 5 – Federal District Court. As a last resort, you may pursue the matter in federal court.
Throughout this process, your doctor’s support is critical. A well-documented letter of medical necessity from your physician can significantly improve your chances at each stage.
Navigating prior authorization rules, plan differences, and appeals processes is a lot to manage alone—especially when you’re also dealing with a health condition. This is where working with a licensed Washington Medicare insurance broker makes a real difference.
At Advisor Health Benefits Group, Kevin Husted has spent nearly 30 years helping Washington residents understand their Medicare options and enroll in plans that fit their health needs and budget. As the manager of the Washington Health Plan Finder Enrollment Center in the Tri-Cities, Kevin has direct knowledge of the plans available in your area—including how each one handles prior authorization.
Kevin helps clients:
And as always, there is no cost to you for using a licensed insurance broker. Kevin is compensated by the insurance carriers, not by clients. You get personalized, expert guidance at no charge.
Learn more about Kevin’s background and approach on his broker profile page.
If you’re turning 65 this year or transitioning off employer coverage, it’s worth understanding how prior authorization works before you choose a plan—not after a claim is denied.
Kevin recommends reaching out at least 3 to 6 months before your Medicare start date to review your options. This gives you time to:
Our Medicare checklist for turning 65 walks you through every step of the enrollment process.
Official Medicare resource: For up-to-date information on Medicare coverage rules and your rights, visit Medicare.gov.
Washington residents are searching for clear answers about how prior authorization works under Medicare in 2026—and for good reason. The rules just changed significantly. Below are the most common questions Kevin Husted hears from Medicare enrollees across the Tri-Cities, Kennewick, Richland, Pasco, and throughout Washington State, along with straight answers that cut through the confusion.
Yes—and Washington is one of only six states in the country directly impacted by a landmark new federal pilot program. Starting January 1, 2026, Original Medicare (Traditional Medicare) beneficiaries in Washington are now required to obtain prior authorization for 17 specific medical procedures under a CMS initiative called WISeR (Wasteful and Inappropriate Service Reduction). The other five pilot states are Arizona, New Jersey, Ohio, Oklahoma, and Texas.
This is a major departure from how Original Medicare has historically operated. For decades, prior authorization was rarely required under Traditional Medicare—it was primarily a Medicare Advantage issue. That has now changed for Washington beneficiaries. If your doctor recommends one of the 17 targeted procedures and you have Original Medicare, your provider must receive CMS approval before your care can move forward or be covered. If you’re in the Tri-Cities and you or a family member is on Original Medicare, this change is worth understanding now—before you need a procedure, not after.
The WISeR pilot program specifically targets procedures that CMS has flagged for high rates of fraud, waste, or overuse. As of January 1, 2026, the following services require prior authorization for Original Medicare beneficiaries in Washington State:
If your doctor recommends any of these procedures and you have Original Medicare in Washington, your provider must submit a prior authorization request to CMS—and receive approval—before the service is performed. If the service is performed without authorization, Medicare will not pay, and you could be held responsible for the full cost. Ask your provider in advance whether your planned procedure is on the WISeR list.
Yes, and it’s very common. According to KFF, 99% of Medicare Advantage enrollees nationally are required to obtain prior authorization for at least some services—and Washington is no exception. Medicare Advantage plans available in the Tri-Cities (Benton and Franklin Counties), Spokane, Seattle, and across Washington routinely require prior authorization for inpatient hospital stays, skilled nursing facility care, chemotherapy, MRIs and CT scans, durable medical equipment, home health services, and specialist referrals.
Here’s what makes this complicated: each Medicare Advantage plan sets its own prior authorization policies within the rules CMS allows. That means Plan A and Plan B—both available in Richland or Kennewick—can have very different requirements for the exact same procedure. One plan might approve an MRI without PA; another might require it. During Medicare Open Enrollment each fall, comparing a plan’s prior authorization requirements for your specific health needs is just as important as comparing premiums. A local broker like Kevin can walk you through this side-by-side.
As of January 1, 2026, CMS implemented new mandatory response time requirements for prior authorization decisions. Here’s exactly how the timelines work:
Before 2026, prior authorization decisions could drag on for weeks with few consequences for the insurer. These new timelines create real accountability. If a plan misses a deadline, you have grounds to escalate your case. Knowing these rules—and keeping records of when you submitted your request—gives you leverage if a plan is slow to respond.
A denial is not final. Under federal law, Washington Medicare beneficiaries have a clearly defined, multi-level appeals process that gives you real recourse when a prior authorization is rejected. Here’s how it works:
The most important thing you can do is act quickly and get your doctor involved immediately. Physicians in the Tri-Cities area who are familiar with CMS documentation standards can often make the difference between an upheld denial and a successful appeal. Don’t navigate this alone—a licensed broker can refer you to the right resources.
Not fully, and this surprises many Washington beneficiaries. Medigap plans—like the popular Plan G—are designed to pay your share of costs after Original Medicare pays. That means if Original Medicare denies a prior authorization request under the new WISeR program, Medigap has nothing to pay on top of. The authorization has to be approved at the Medicare level first.
Here’s the practical implication for Tri-Cities residents: if you have Original Medicare plus a Medigap Plan G and your doctor recommends one of the 17 WISeR procedures, your provider still needs to get CMS approval before performing the procedure. If that approval is denied and you don’t successfully appeal, neither Medicare nor your Medigap plan will cover the cost. This doesn’t mean Medigap isn’t valuable—it absolutely is—but it does mean that Washington’s inclusion in the WISeR pilot program creates a new layer of complexity for Medigap policyholders that didn’t exist before 2026.
Yes, and it affects more people than most realize. Medicare Part D prescription drug plans—both standalone PDP plans and drug coverage embedded in Medicare Advantage—commonly use prior authorization to control costs and ensure appropriate prescribing. In Washington, you may need prior authorization for:
Part D plans also use step therapy, which requires you to try and fail on a lower-cost drug before the plan will approve a more expensive one. New CMS guardrails have limited the most aggressive step therapy practices, but they still apply in many situations. With the 2026 Part D out-of-pocket cap now set at $2,100, understanding how prior authorization interacts with your drug costs matters more than ever. A local broker can review your specific prescriptions against available Part D plans in Washington to find the plan with the least friction for your medications.
Yes. CMS has formally integrated artificial intelligence (AI) into the WISeR pilot program to help process prior authorization requests more quickly and flag potentially problematic requests for human review. The stated goal is to reduce processing time and make decisions more consistent across providers.
However, this raises legitimate concerns for Washington beneficiaries. Critics—including patient advocates and physician groups—have pointed out that AI systems can make errors, particularly for complex or unusual cases. CMS has put patient protections in place: AI-assisted decisions must meet the same clinical standards as human reviews, and any denial carries the same full appeal rights regardless of whether a human or algorithm made the initial call. If you or your doctor believes a prior authorization was denied incorrectly—by a human or by an automated system—the appeals process is available to you.
Yes, and in some cases it’s the right move. If your Medicare Advantage plan’s prior authorization requirements are consistently delaying or blocking care your doctor believes is necessary, you have options:
Importantly, under the 2026 CMS continuity of care rule, if you switch Medicare Advantage plans, your new plan must honor any previously approved prior authorizations for at least 90 days. A broker can help Tri-Cities residents compare Washington plans specifically on their prior authorization track records before you make a switch.
The most efficient thing you can do is work with a local, licensed Washington Medicare broker who already understands the plan landscape in your area—and who won’t charge you for the help.
Kevin Husted at Advisor Health Benefits Group in Richland has spent nearly 30 years helping residents of Kennewick, Pasco, Richland, and communities throughout Washington navigate exactly these kinds of Medicare questions. As the manager of the Washington Health Plan Finder Enrollment Center in the Tri-Cities, Kevin has hands-on knowledge of every Medicare Advantage, Medicare Supplement, and Part D plan available in your county—including how each one handles prior authorization for the services that matter most to your health.
Kevin’s guidance is free. Insurance carriers pay licensed brokers directly, so there is no cost to you for a consultation, comparison, or enrollment assistance. Call (509) 524-9611, email Kevin@AdvisorHealthBenefits.com, or schedule a free consultation online to get clear, local answers from someone who has helped thousands of Washington families get the coverage they need.
If you have questions about prior authorization, Medicare Advantage plan options, or anything related to your health coverage in Washington, the team at Advisor Health Benefits Group is here to help.
📍 1446 Spaulding Avenue #302, Richland, WA 99352 📞 1-509-524-9611 ✉️ Kevin@AdvisorHealthBenefits.com
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Kevin Husted is a licensed Washington State health insurance broker and President of Advisor Health Benefits Group. With nearly 30 years of experience and thousands of clients helped across the Tri-Cities and beyond, Kevin specializes in Medicare, individual and family health plans, and small business coverage. Learn more about Kevin.
