BREAKING: CMS proposes more Medicare Advantage ‘guardrails’

The Centers for Medicare and Medicaid Services (CMS) announced it is pursuing further limits on Medicare Advantage plans’ use of prior authorization and artificial intelligence — the latest move in an ongoing effort to address Medicare Advantage guardrails that protect seniors from coverage denials. Here’s what the proposed rules would do and what they mean for Arizona Medicare enrollees.

Why CMS Is Proposing Medicare Advantage Guardrails

Prior authorization — requiring insurer approval before medical care can be delivered — has become one of the most significant complaints from Medicare Advantage enrollees. A Senate Finance Committee investigation found that major Medicare Advantage insurers denied prior authorization requests at rates far higher than originally reported, and that many denials were for care that Original Medicare would have covered without question.

Adding to the concern, many insurers began using artificial intelligence algorithms to make or assist with prior authorization decisions. In some cases, these AI systems were denying care without adequate review by a physician.

What the Proposed Medicare Advantage Guardrails Would Do

CMS’s proposed Medicare Advantage guardrails target several specific practices:

• AI-based denials — Plans would be required to have physician oversight of any AI-assisted prior authorization decision. An algorithm alone could not deny a claim.
• Criteria alignment — Plans would need to use coverage criteria that align with Original Medicare, reducing the ability to deny care that Medicare would otherwise cover.
• Faster decisions — Stricter timelines for prior authorization decisions, particularly for urgent care situations.
• Continuity of care — Protections for patients who are mid-treatment when a plan changes its network or coverage.

What This Means — and What It Doesn’t Fix

The proposed rules are a step in the right direction. However, they don’t eliminate the fundamental structure of Medicare Advantage guardrails — they only constrain how plans can implement them.

According to CMS, even with these new rules in place, Medicare Advantage plans will still require prior authorization for many services. Original Medicare does not require prior authorization for most care. That fundamental difference remains.

The Alternative: Original Medicare With Plan G

If you’re concerned about prior authorization, AI-based denials, or narrow networks, the most reliable solution is returning to Original Medicare with a Medicare Supplement Plan G.

With Plan G, you pay the Part B deductible once per year — $257 in 2026 — and after that, Medicare and Plan G cover your costs for the year. No prior authorization. No AI deciding your care. No networks.

Questions About Your Medicare Coverage Options?

I’m Andy Orlikoff, an independent Medicare broker in Surprise, AZ. I help Arizona seniors understand what the latest Medicare Advantage guardrails and policy changes mean for their coverage — and whether Original Medicare with Plan G is a better fit.

Call or text: (623) 742-3878
Email: andy@azhealth.us
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