Your Medicare Advantage plan must follow regular Medicare's coverage rules

If you’re in a Medicare Advantage plan, the plan has to follow traditional Medicare’s national and local coverage decisions and general coverage rules. A plan can write its own criteria only where Medicare’s rules aren’t fully set. Those criteria must be based on current evidence in widely used treatment guidelines or qualifying clinical literature and must be public. Before a plan issues a medical-necessity denial, a licensed physician or other appropriate health professional with expertise relevant to the requested service must review it.

Once your plan approves a course of treatment, the approval stays valid as long as medically necessary under the applicable coverage criteria, considering your medical history and your treating provider’s recommendation. If you’re in the middle of treatment and switch to a new plan, the new plan must give you at least 90 days without disrupting the treatment or requiring reauthorization. You don’t need to apply for these protections. Any Medicare Advantage organization that uses prior authorization or other utilization-management policies must also have a committee that reviews those policies against Medicare’s rules each year.

The Centers for Medicare & Medicaid Services issued the rule in April 2023. CMS Administrator Chiquita Brooks-LaSure approved the document, and Health and Human Services Secretary Xavier Becerra signed it. The protections applied to coverage starting January 1, 2024. The rule also cracked down on misleading Medicare Advantage ads. CMS’s 2027 rule removed the committees’ health-equity duties but left these coverage and continuity protections in place.