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Author: Andy

‘Delay’ and ‘Deny’: Even Health Insurance Companies Agree Prior Authorization Process Is Broken

Andy |

April Dembosky

Ocean McIntyre goes through a file folder of health insurance claims and denial letters at her home in Panorama City on Feb. 10, 2026.  (Jules Hotz for KQED)

When Ocean McIntyre started having vision problems at age 34, her health plan took a month to authorize a doctor visit.

When pressure in her brain started crushing her optic nerve, she spent three months tangled in bureaucratic red tape before the insurer finally permitted her to see a specialist, a neuro-ophthalmologist.

“He said if you had been seen earlier, we could have preserved your vision,” McIntyre remembered. “Now we’re just trying to see if we can save any of your vision. That was the first time it really clicked that the life that I had before was over.”

After a wide-ranging career as a tattoo artist, a private pilot, and a research assistant at NASA’s Jet Propulsion Lab near Pasadena, McIntyre is now 51, legally blind and struggling to find work. “I have no peripheral vision at all. It’s like looking through a straw, and what I see is semi-clear in one eye and completely blurry in the other,” she said. “I fall, I trip on things all the time, even in my own house. I’m obviously not flying anymore, not driving a car anymore.”

For decades, patients like McIntyre and their doctors have pressed California and other state lawmakers to rein in health insurers’ ability to review or refuse coverage for medical services after a physician has ordered them, a practice known as prior authorization. But the conversation shifted in December 2024 when Luigi Mangione allegedly murdered UnitedHealth CEO Brian Thompson, using bullets etched with the words “delay” and “deny.” The next year, an unprecedented 31 states, at least, passed laws limiting the use of prior authorization, almost all with bipartisan and near-unanimous support.

In 2025, 31 U.S. states passed prior authorization reforms. (Map: Marnette Federis/KQED)

While momentum for legislative change had already been building, several industry insiders and observers said the assassination of an insurance executive, and especially the public outcry that followed, was the catalyst that pushed so many laws over the finish line in 2025. Tens of thousands of people took to social media to both condemn the violence and to air their grievances about insurance tactics and barriers to care.

“It really highlighted for the country this amount of anger,” said Miranda Yaver, health policy professor at the University of Pittsburgh. “And I think that placed pressure on state legislatures.”

Health insurers felt the pressure, too, as lawmakers complained during committee hearings about their own experiences with prior authorization before voting in favor of local bills.

By summer 2025, a coalition of insurance companies issued a pledge to voluntarily streamline, simplify, and reduce the use of prior authorizations. Especially where state legislation aligned with these principles or was narrowly tailored, the insurance industry was more receptive than it had been in the past. Where there was still friction, insurance lobbyists stated their objections, but often struck a conciliatory tone.

Paul Markovich, president and CEO of Ascendiun, the parent company of Blue Shield of California, testifies before the House Committee on Ways and Means with other health insurance CEOs on Capitol Hill, in Washington, on Jan. 22, 2026. (Jose Luis Magana/AP Photo)

“Prior authorization process today sucks. We all take accountability for it,” saidPaul Markovich, CEO of Blue Shield of California, at a congressional committee hearing in January featuring a panel of five health insurance executives. “We are fixing it by reducing the number of services that are covered, offering an online service, and standardizing electronic submission of data.”

Prior authorization started out as a tool insurers used to control costs and tosafeguard patients against unnecessary or harmful treatments. It is typically applied to high-cost items, like experimental treatments, hospitalizations and surgeries, and certain prescription drugs.

For example, back surgeries are often denied because clinical trials show they provide little to no benefit to people who suffer from back pain compared to exercise and physical therapy. Brand-name medications can often be replaced with equally effective, but significantly cheaper, generic alternatives.

Two health insurance denial letters lie on Ocean McIntyre’s table, at her home in Panorama City. Many more are stored in boxes and file folders of communication letters from her health insurance on Feb. 10, 2026. (Jules Hotz for KQED)

“These efforts help keep coverage as affordable as possible,” said Chris Bond, spokesperson for AHIP, a national trade association for the health insurance industry.

But in more recent years, doctors complained that insurers were abusing prior authorization, applying it to more services or using it as a tactic to delay and deter patients away from care. In a 2024 national survey, doctors said they and their staff spent an average of 13 hours a week dealing with prior authorization requests; 23% of doctors said their patients had been hospitalized because of prior authorization delays, 18% said they’d experienced a life-threatening event, and 8% said a patient suffered permanent disability or death.

The mountains of paperwork and constant second-guessing by insurers drive burnout and push doctors into early retirement, said René Bravo, a pediatrician in San Luis Obispo and president of the California Medical Association.

“There is nothing that causes physicians’ blood pressure to elevate like prior authorization,” he said. “You just say the word, and doctors bristle.”

California targets insurance companies

States are taking different approaches to regulating the insurance industry’s use of prior authorization. Some, like Nebraska and North Dakota, focused on expediting the process, mandating timelines for when reviews must be completed, while others restricted the use of artificial intelligence in making determinations.

Many states, including Texas, Arkansas, and West Virginia, have instituted “gold card” programs that exempt doctors from prior authorization if the treatments they order already have a high rate of approval. Others, including Rhode Island and Montana, focused on exempting certain treatments, such as preventive care, insulin, mental health and substance abuse treatment, or some cancer care.

David H. Aizuss, M.D., F.A.C.S., an ophthalmologist and chair of the board of trustees at the American Medical Association, in his office in Encino, California, on Feb. 10, 2026. (Jules Hotz for KQED)

“The California law is different. It puts the onus on the health plans,” said David Aizuss, an ophthalmologist in Los Angeles and chair of the board of trustees at the American Medical Association, which has been tracking state legislation.

SB 306 said that if a health insurer approves a medical service more than 90% of the time in one year, then it can’t require prior authorization for that service the next year.

“This creates a data-driven, common-sense approach,” said state Sen. Josh Becker, D-Menlo Park, who authored the bill. “If you’re approving it anyway, don’t make patients, providers jump through hoops.”

Though attempts to pass a previous version of this bill petered out in 2023, Gov. Gavin Newsom’s office was particularly involved in the passage of SB 306, mediating differences between doctors who supported it and insurers who opposed it, and directing the state Department of Managed Health Care to offer technical assistance.

The regulator is leading the implementation of the law. By July 2026, officials will instruct insurers on how to report the statistics that will be used to list procedures and medications that will be exempted from prior authorization, which regulators expect to publish by July 2027.

Aizuss believes a range of medications for hypertension, diabetes, asthma, and arthritis will make it onto the list, as well as certain outpatient mental health treatments and cancer surgeries.

He’s hopeful that California’s broad approach will lead to more overall transparency and be more effective than other states. Insurers have found loopholes to skirt around the requirements of gold card laws, he said, and the burden is on doctors to prove they should be exempt from prior authorization. For example, in Texas, only 3% of doctors have qualified for gold card status, Yaver said. The California law, by contrast, requires insurers and regulators do the legwork. “This is a positive step toward relieving physician administrative burden,” Yaver said.

Whatever the approach, McIntyre is relieved to see progress in California and across the country. She said no one should suffer a heart attack or a cancer relapse, or lose their vision, because they had to wait for care.

Millions may drop ACA coverage — and raise health insurance costs for everyone else

Andy |

If you are in this position reach out to us, there may be more affordable option that you can qualify for.

www.AZhealth.us | Andy Orlikoff | 623-742-3878

Greg Iacurci

Millions of people are likely to drop their health insurance now that enhanced premium subsidies for consumers who buy coverage on the Affordable Care Act marketplace have expired. That could increase costs for remaining enrollees, leading some experts to warn of a potential “death spiral” in the ACA market.

The lapse of enhanced premium tax credits at the end of 2025 led insurance premiums to more than double for the average subsidy recipient, to $1,904 per month in 2026 from $888 last year, according to estimates from KFF, a nonpartisan health policy research group.

Young, relatively healthy people are the most likely to drop their policy if they deem premiums to be too high and think coverage is not worth the cost, economists said.

That would leave an older, sicker population of enrollees, who are more likely to use their insurance and require costly care, economists said — which might prompt insurers to raise premiums further to offset the higher costs in a self-reinforcing cycle.

“If these [relatively young, healthy] individuals, whose health care costs are lower on average, exit the risk pool, the average cost of care will increase and thereby cause premiums to increase further,” Meredith Rosenthal, chair of the Department of Health Policy and Management at Harvard University’s T.H. Chan School of Public Health, said recently in a written interview with the university.

“The worry is that this process can spiral (known as a “death spiral”) and lead to further disenrollment and even higher premiums,” she said.

Millions of young people may drop ACA coverage

An Obamacare sign at a Miami insurance agency on Nov. 12, 2025.

Joe Raedle | Getty Images

About 22 million Americans received enhanced premium subsidies in 2025.

The Urban Institute and The Commonwealth Fund estimate that 7.3 million people will leave the ACA marketplace in 2026 due to the loss of enhanced premium subsidies. About 5 million of them would go uninsured, they wrote in a joint analysis, rather than find insurance elsewhere.

Young adults would see the largest increase in the number of uninsured people, they said.

In fact, 19- to 34-year-olds account for nearly half — about 2.3 million — of the anticipated increase in the number of uninsured people, according to Jessica Banthin, a senior fellow at the Urban Institute and co-author of the analysis.

By comparison, about 500,000 of those who will be uninsured are 55 to 64 years old, Banthin said.

“It all comes down to who really feels like they need to have health insurance,” said Emma Wager, a senior Affordable Care Act policy analyst at KFF.

There’s evidence insurers raised premiums for 2026 due to a riskier population of insured consumers, experts said.

Insurers raised their gross premiums by an estimated 26% for 2026, on average, according to KFF. This is the total premium, including the consumer’s share and whatever is covered by premium tax credits.

Insurers indicated in filings to state regulators that 4 percentage points of that 26% is due to their expectations that healthier people would drop coverage if the enhanced premium tax credit lapsed, Wager said.

The rest of the increase is due to other factors inflating the cost of health care, such as new specialty drugs becoming available, the cost of labor and consolidation among medical providers, Wager said.

The public will get a clearer picture of how many people dropped their ACA marketplace coverage and the demographics of those individuals when data becomes available over the summer, Wager said.

Why death spiral concerns may be premature

Colorado residents fill out cards and share their stories for content to send to congressional representatives regarding health-care cuts on Nov. 1, 2025, the first day of ACA open enrollment, in Northglenn, Colorado.

Tom Cooper | Getty Images Entertainment | Getty Images

Some policy experts say that warnings of a death spiral in the ACA marketplace are premature.

For one, the disappearance of enhanced subsidies seems to be a one-time shock to the system, they said.

“I think the death spiral concern is understandable, but may be a slight exaggeration,” Michael Gusmano, a professor of health policy at Lehigh University, wrote in an e-mail. “What seems likely is that the loss of people from the overall pool will lead to increases in price — and this will further erode the willingness of people to sign up.”

Additionally, the way premium tax credits were designed should prevent a death spiral, policy experts said.

The tax credit structure caps households’ out-of-pocket expenses for insurance premiums as a percentage of household income. For example, the enhanced federal subsidies capped outlays at 8% of household income, while the lowest earners paid 0%.

While the enhanced subsidies have disappeared, the standard premium tax credits — which have been in place since 2014 — remain.

Now, out-of-pocket premiums are capped at roughly 10% of annual income for qualifying consumers. The cap declines on a sliding scale, down to about 2% for lower earners.

The more money you take away from the subsidies the greater the prospect of death spiral is.

Gerard Anderson

professor of health policy and management at Johns Hopkins Bloomberg School of Public Health

These income caps would likely prevent a death spiral, economists said. If insurers raise premiums, those increases are borne largely by the federal government via tax credits, not consumers, they said.

“All those higher premium costs mostly get translated into higher government subsidies,” John Graves, a professor of health policy and medicine at Vanderbilt University, wrote in an e-mail.

Millions fewer people may enroll, but there would still be “stable risk pools” by virtue of the income caps, he wrote.

Consumers least likely to sign up

Patients are prepared for surgery on the opening day of UCI Health – Irvine in Irvine, California, Dec. 10, 2025.

Paul Bersebach/MediaNews Group/Orange County Register via Getty Images

Aside from young consumers, those least likely to sign up or re-enroll in ACA marketplace coverage are people who no longer qualify for any premium tax credits, experts said.

These are consumers who earn more than 400% of the federal poverty level, which equates to $62,600 for a one-person household.

Many of these households qualified for enhanced subsidies but are no longer eligible — meaning they must pay the full, unsubsidized insurance premium out of pocket.

The Urban Institute and The Commonwealth Fund estimate that the average annual premium for consumers over the subsidy cliff jumped to about $8,500 in 2026 from about $4,400 in 2025.

In 2025, about 3% of ACA enrollees — nearly 725,000 people — earned between 400% and 500% of the federal poverty line, for example, according to a Bipartisan Policy Center analysis of federal data.

How an ACA death spiral becomes more likely

Something that policy experts say would be more likely to trigger a death spiral: Converting the current subsidy structure into a fixed-dollar payment for consumers, an idea that Republican lawmakers and President Donald Trump have broached.

In that case, the premium increase would be borne entirely by individuals rather than by the federal government, Graves said.

“The more money you take away from the subsidies, the greater the prospect of death spiral is,” said Gerard Anderson, a professor of health policy and management at Johns Hopkins Bloomberg School of Public Health.

#surprise, AZ

#healthinsurance

Trump’s Flat Medicare Advantage Rate May Harm Seniors’ Choices

Andy |

Bruce Japsen

Insurance CEOs Get Congress’s Ire For Rising Health Costs

Even before the Trump administration said the 2027 Medicare Advantage payment rate will be flat, insurers were pulling back from unprofitable markets.

But rising costs coupled by flat rates could trigger further withdrawals of health insurers from states and counties across the country, disrupting the choice of plan for millions of older adults enrolled in Medicare Advantage.

Already, some of the biggest names in health insurance including UnitedHealth Group’s UnitedHealthcare, CVS Health’s Aetna, Elevance Health, parent of several Blue Cross and Blue Shield plans, and Humana pulled back this year from sales of Medicare Advantage plans in certain markets after years of expanding their geographic footprints.

Take UnitedHealthcare, for example. The health insurer exited certain marketsfor this year and expects its Medicare Advantage enrollment to contract by more than 1.1 million older adults, the company said last Tuesday in its fourth quarter and annual 2025 earnings report.

When health insurers leave markets, it forces Medicare Advantage enrollees to pick new plans which may or may not have the same doctors and hospitals or benefit packages. Medicare Advantage plans contract with the federal government to provide traditional coverage available in traditional Medicare plus extra benefits and services to seniors, such as disease management and nurse help hotlines with some also offering vision, dental care and wellness programs.

Last week, the Centers for Medicare & Medicaid Services (CMS), which is run by a Trump-appointed administrator in celebrity physician Dr. Mehmet Oz, said they planned to raise rates paid to health insurers by 0.09 percent, which was less than what health insurers were expecting.

The lobby for health insurers already hinted last week that older Americans enrolled in Medicare Advantage plans could see more services and benefits reduced due to the proposed “flat program funding” proposed by CMS.

“Health plans welcome reforms to strengthen Medicare Advantage,” said Chris Bond, spokesman for America’s Health Insurance Plans (AHIP). “However, flat program funding at a time of sharply rising medical costs and high utilization of care will impact seniors’ coverage. If finalized, this proposal could result in benefit cuts and higher costs for 35 million seniors and people with disabilities when they renew their Medicare Advantage coverage in October 2026.”

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Such plans, which provide benefits for more than half of the nation’s Medicare beneficiaries, have been hit hard by rising costs in the last two years in part because seniors have a pent up demand for healthcare following the Covid-19 pandemic when many patients delayed treatment.

UnitedHealthcare is no exception. Its full year adjusted 2025 medical care ratio, which is the percentage of premium revenue that goes toward medical costs, was 88.9% compared to 85.5% in 2024. Adjusted medical care ratio was more than 91% in the fourth quarter.

“As part of our efforts to address elevated trend and funding cuts, we planned for some Medicare Advantage contraction in 2026,” UnitedHealthcare chief executive Tim Noel told analysts on UnitedHealth Group’s fourth quarter and full year 2025 earnings call last week. “We now expect UHC Medicare Advantage contraction will be in the range of 1.3 million to 1.4 million members for the full-year, including group, individual and D-SNP.”

Elevance Health, too, which is the nation’s second-largest health insurance company, also disclosed last week that it was seeing rising healthcare costs. The company’s benefit expense ratio rose to 93.5 percent in the fourth quarter.

Elevance’s benefit expense ratio gradually rose over the last year. It was 91.3 percent in the third quarter, 88.9% and in the second quarter and 86.4% in the first quarter, according to earnings reports issued throughout last year.

“For 2026, we made deliberate changes to our plan offerings and intentionally exited select geographies, prioritizing plans that deliver value to members while producing sustainable financial performance,” Elevance chief financial officer Mark Kaye told analysts on the company’s fourth quarter and annual 2025 earnings call. “As you heard from (Elevance CEO) Gail (Boudreaux), we now expect Medicare Advantage membership to decline in the high teens percentage range in 2026 while achieving meaningful margin improvement.”

Insurance companies won’t disclose the markets they are participating in for Medicare Advantage for 2027 until this fall. Stay tuned.

Inspector General’s Report Sounds the Alarm on a Huge Medicare Advantage Plan Problem

Andy |

Christy Bieber

Retirees on Medicare Advantage are missing out on crucial coverage, and their health could suffer because of it.

Many seniors choose a Medicare Advantage plan over traditional Medicare because they hope the plan will provide broader coverage. In fact, an estimated 32.8 million people — more than half of all Medicare recipients — were enrolled in an Advantage plan as of 2024.

Unfortunately, these Medicare Advantage plan enrollees are at risk because of a serious gap in coverage. This troubling news comes from a report released by the Office of the Inspector General.

Here are some details on the coverage gap, along with some insight into what this could mean for retirees.

Inspector General reveals that Medicare Advantage has a serious gap in coverage

According to a report prepared by the IG for the Department of Health and Human Services, behavioral healthcare is covered by managed care plans for the majority of Medicare enrollees.

Behavioral healthcare is care for mental health conditions and substance abuse disorders. When this care is available as part of a managed care plan, it is typically covered only if plan enrollees can find an in-network doctor.

Advantage plans must provide a list of in-network providers. This helps seniors enrolled in these plans understand their care options and find a provider who will take their insurance.

Unfortunately, the Inspector General’s report revealed that the majority of Medicare Advantage plans had “limited networks of behavioral health providers.”

Even worse, many of the providers listed as participating in the plan were “ghost providers.” Their showing up on the list makes the network look larger, but they don’t actually provide any services to enrollees.

This is a huge issue, as the networks look comprehensive, but seniors who are signed up for Medicare Advantage plans end up with few to no options for behavioral healthcare.

Missing out on behavioral healthcare can be a huge problem

Previous IG reports have shown that there were fewer than five active behavioral healthcare providers per 1,000 enrollees in Medicare Advantage plans.

Since the Centers for Disease Control and Prevention has warned that around 4% of adults 70 and over suffer from depression, and roughly 17% of the elderly have health problems resulting from drug and alcohol abuse, a lack of access to behavioral healthcare providers could be a huge problem.

Unfortunately, covering this treatment out-of-pocket could put a significant strain on retirees, many of whom struggle to cover their expenses on Social Security and retirement plan distributions.

Retirees who are exploring their Medicare Advantage options should be alert to these issues and should compare plans carefully.

How can Medicare Advantage plan enrollees protect themselves?

If an Advantage plan lists a provider as being in-network, retirees may wish to call and verify this so they ensure they aren’t tricked by a ghost provider. Otherwise, they may not get the care they need, or may have to pay for it out of retirement savings from a 401(k) plan or other sources.

This is just one of many access-to-care issues retirees may face.

While Medicare and Medicare Advantage help provide coverage, there are gaps. Retirees should ensure they invest wisely, so they have the funds they need to cover any medical services that may be required.

Don’t put yourself at risk.   We can help with a true Medigap plan that will protect you against these pitfalls.

Andy Orlikoff

www.AZhealth.us

623-742-3878

#surprise,AZ #SunCity,AZ #medicare

The Great Medicare U-Turn: How to Switch Back to Original Medicare

Andy |

The Great Medicare U-Turn: How to Switch Back to Original Medicare

If you’ve spent the last year realizing that “Advantage” doesn’t always feel like an advantage, you aren’t alone. Maybe your favorite specialist left the network, or you’re tired of asking for “prior authorization” just to get an MRI.

The good news? If you’re reading this in January, the door is wide open for a change. But before you jump ship, there’s a specific sequence you need to follow to avoid getting stranded without coverage.

1. The “Right Now” Window: The 2026 MA OEP

Since today is January 26, 2026, you are currently in the Medicare Advantage Open Enrollment Period (MA OEP). This runs from January 1 to March 31. The Fall Window: Annual Enrollment Period (AEP) Dates: October 15 – December 7.

During this time, you can:

Note: If you make the switch this month, your new coverage will typically begin on the 1st of the following month.

2. The Medigap “Trap”: Don’t Drop Your Plan Yet!

This is the most critical part of the U-turn. Unlike Medicare Advantage, which must take you regardless of health, Medigap (Medicare Supplement) providers in most states can use medical underwriting.

The Risk: If you have a pre-existing condition, a Medigap insurer can charge you more or deny you a policy entirely unless you have a “Guaranteed Issue Right.”

Do you have a “Guaranteed Issue Right”?

You generally don’t need a health screening if:

The Golden Rule: Secure your Medigap policy and get an acceptance letter before you officially disenroll from your Medicare Advantage plan.

3. Your 2026 Transition Checklist

Switching back involves a three-step dance. If you miss a step, you could face lifetime penalties or massive bills.

Step Action Why it matters
Step 1 Apply for Medigap Ensures your “gap” coverage is locked in before you leave your current plan.
Step 2 Join a Part D Plan Medicare Advantage usually includes drugs; Original Medicare does not. Missing this causes a late-enrollment penalty.
Step 3 Confirm Disenrollment Joining a standalone Part D plan usually automatically triggers your exit from Medicare Advantage, but always call your plan to confirm.

4. What Original Medicare Costs in 2026

Since you’re moving back to the “Original” way of doing things, here is a quick look at the 2026 rates:

Why People are Making the Switch

In 2026, the maximum out-of-pocket (MOOP) for Medicare Advantage plans can be as high as $9,250. For someone facing a major surgery or chronic illness, that “low premium” plan can suddenly become very expensive. Medigap Plan G, by contrast, covers nearly everything after you pay the small Part B deductible, giving you total “cost predictability.”

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