CMS’s WISeR Model Faces Potential Repeal Following GAO Determination
On May 20, 2026, Congressional Democrats led by Senators Ron Wyden (D-OR), Rep. Suzan Delbene (D-WA)...
Prior Authorization & Utilization Management
Utilization management is a central feature of Medicare Advantage (MA) that is intended to reduce unnecessary spending and ensure the care beneficiaries receive is medically necessary. Most MA plans use tools such as prior authorization, step therapy, and medical necessity reviews for some services, in contrast to traditional Medicare. MPI’s work on this topic examines how these policies are implemented, regulated, and updated across MA and related Medicare programs, and the balance they strike between containing costs and maintaining access to needed care.
Additional work explores efforts to incorporate more utilization management into traditional Medicare and streamline prior authorization, as well as emerging technologies used in coverage determinations and the effects of utilization management on beneficiaries and providers.
Explore policy proposals related to Utilization management in our Medicare Advantage Compendium.
CMS Suspends New Medicare Advantage Prior Authorization Transparency Rules Amid Public Concerns About Care Denials
CMS’ decision to suspend enforcement of key prior authorization and utilization management rules i...
What’s Next for Prior Authorization in Medicare Advantage
On September 18, 2025, Georgetown’s Medicare Policy Initiative hosted a briefing titled What’s N...
Fact Sheet: Artificial Intelligence in Medicare Advantage – Opportunities and Risks
Read “Artificial Intelligence in Medicare Advantage – Opportunities and Risks” here.
Artificial Intelligence in Medicare Advantage—Opportunities and Risks
This white paper synthesizes findings from semi-structured interviews and a closed-door roundtable c...
New CMS WISeR Model Revives Concerns of Prior Authorization and Artificial Intelligence
In this MPI blog by Neil Patil and Jack Hoadley, we take lessons learned from prior authorization in...
The Trump Administration’s First Regulatory Action on Medicare Advantage Omits Some Prior Authorization Guardrails
By Neil Patil and Carrie Graham On April 4, 2025, the Centers for Medicare & Medicaid Services (...
Fact Sheet: Prior Authorization in Medicare Advantage
Read “Prior Authorization in Medicare Advantage” here.
Prior Authorization in Medicare Advantage: Balancing Patient Access and Program Costs
At this February 4, 2025 event, policy experts discussed the use of prior authorization in Medicare ...