Prior authorization was one of the main concerns that our retirees raised about using a Medicare Advantage plan. Your concerns were heard. We negotiated aggressively with the company to build a customized Medicare Advantage plan that significantly limits the types of procedures and services that require prior authorization.

As a result of this bargaining, prior authorization has been removed from the majority of procedures for which Aetna typically requires it. Most tests, including MRIs and CAT scans, will not require prior authorization. Prior authorization will never be required for emergency or urgently needed services.

Every two years, Aetna, the city and the Municipal Labor Committee will review its prior authorization program and will discuss whether changes are appropriate.

What is prior authorization? 

Prior authorization is a management process used by insurance companies to determine if a prescribed medical procedure or service will be covered in part or in full by the insurance company. It is meant to ensure that these products or services are medically necessary.

What procedures or services would not require prior authorization?

No prior authorization will be needed for the vast majority of services, including:

• MRIs
• CT scans
• PET scans
• sleep study
• radiation therapy
• pain management
• diagnostic cardiology

These services typically require prior authorization in Medicare Advantage plans, but don't need it in the new customized plan.

What procedures or services would need prior authorization?

You would need to get prior authorization from Aetna for the following services:

• Acute hospital inpatient care (not ER)
• Long-term acute care
• Acute physical rehabilitation
• Admission to a skilled nursing facility
• Durable medical equipment
• Home care services
• Substance abuse treatment
• Transplants
• Any service not covered by Medicare, including cosmetic surgery
• Services that could be considered experimental and investigational in nature'

Who is responsible for getting prior authorization?

Your in-network doctor, not you, is responsible for reaching out to Aetna to get prior authorization when necessary. When prior authorization is required and your in-network provider does not get the prior authorization, Aetna will hold you harmless.

Out-of-network doctors are not required to get prior authorization. However, if the services they provide are not covered under Medicare or are not medically necessary, there is a risk you will not be reimbursed for the service after Aetna reviews the claim. Like in any Medicare plan, procedures that are not covered or are not medically necessary are subject to denial. In cases that might not fit these two criteria, we strongly recommend that your doctor speak with Aetna in advance to avoid unexpected costs.

What is the timeframe for prior authorization?

Of the limited services that require prior authorization, the majority will be decided within 72 hours or less if it is a nonurgent, scheduled service. If the service or procedure is urgent, a decision will be made in one day or, in many cases, it will be granted the same day. For emergency services, prior authorization is never required.

A “safe harbor” provision

To ensure a smooth transition, for the first 120 days after the new plan takes effect, there will be no denial of any Medicare-covered services by in‑network doctors who do not submit for prior authorization. During this period, Aetna will pay these claims and send a letter to the in‑network provider and the member receiving the medical services to educate them regarding the plan's prior authorization requirements