Prior Authorization Requirements in Medicare Advantage and County Social Vulnerability

To assess whether Medicare Advantage (MA) beneficiaries in socially vulnerable counties face more restrictive prior authorization (PA) requirements.

Cross-sectional analysis of 2945 US counties in 2022.

The primary outcome was the mean percentage of Medicare-covered service categories requiring PA across all MA plans in a county, adjusted for service mix and plan enrollment and derived from the CMS MA benefit, landscape, and enrollment files. Secondary outcomes included county-level PA rates for selected service categories, the number of plans with more vs less restrictive PA policies, and mean monthly premiums. The exposure was the county-level Social Vulnerability Index (SVI) subdomains (socioeconomic status, household characteristics, racial/ethnic minority status, housing and transportation), categorized into deciles. Unadjusted linear regression models were used, weighted by county MA enrollment.

Counties in the highest vs lowest SVI decile in the socioeconomic domain had overall PA rates that were 7.2 percentage points (PP) higher ( P  < .001), with the largest gap for psychiatric services (16.9 PP; P  < .001). Conversely, mean monthly premiums declined across socioeconomic deciles, from $29 in the first decile to $8 in the 10th ( P  < .001). Total plan counts were stable across deciles, but the composition differed: The most vulnerable counties offered 5 fewer plans with less restrictive PA policies and 4 more plans with more restrictive policies (both P  < .001).

MA beneficiaries in socially vulnerable counties face more restrictive PA requirements, especially for psychiatric services. These disparities may compound existing structural barriers and warrant consideration in future MA policy reforms.