Even health insurance companies now admit that the prior authorization process is broken. Major insurers including UnitedHealthcare, Cigna, CVS/Aetna, and Humana publicly acknowledged the problem in congressional testimony and industry statements — while still continuing to use prior authorization as a cost-control mechanism. Here’s what’s happening and what it means for Medicare enrollees in Arizona.
Insurers Admit the Prior Authorization Process Is Broken
The insurance industry’s own trade association, AHIP, has called for prior authorization reform — acknowledging that the current system creates unnecessary delays and burdens for patients and physicians. Several major insurers committed to reducing the use of prior authorization for certain services, following mounting pressure from Congress, physicians, and patient advocates.
But commitments and action are different things. Despite these acknowledgments, KFF research shows that Medicare Advantage plans continue to require prior authorization for a wide range of services — and denial rates remain high.
Why the Prior Authorization Process Is Broken by Design
The prior authorization process is broken not by accident but by financial incentive. Every time a prior authorization is denied and a patient doesn’t appeal, the insurer keeps the premium without paying the claim. The system financially rewards denial — which is why reform commitments rarely translate to meaningful change.
Common services requiring prior authorization in Medicare Advantage plans include:
Inpatient hospital admissions
Skilled nursing facility stays
Chemotherapy and cancer treatments
Imaging (MRI, CT scans)
Home health services
Durable medical equipment
What Congress and CMS Are Doing
The Centers for Medicare and Medicaid Services (CMS) has implemented new prior authorization rules requiring Medicare Advantage plans to make decisions faster and to align coverage criteria more closely with Original Medicare. However, these reforms don’t eliminate prior authorization — they only constrain how it’s administered.
The Alternative: No Prior Authorization Required
Original Medicare does not require prior authorization for most services. If Medicare covers a procedure and your doctor orders it, it’s covered — without an insurance company’s approval process standing in the way.
With a Medicare Supplement Plan G, your costs after the Part B deductible ($283 in 2026) are zero for covered services. No delays. No denials. No fighting with insurance companies.
Questions About Your Coverage in Arizona?
I’m Andy Orlikoff, an independent Medicare broker in Surprise, AZ. I don’t sell Medicare Advantage. I help Arizona seniors avoid the prior authorization process entirely by choosing Original Medicare with Plan G.
Millions of Americans could drop ACA coverage in 2026 if enhanced premium subsidies expire — and the ripple effect could drive up costs for everyone who stays enrolled. For Arizona residents who rely on the ACA marketplace, here’s what’s at stake and what your options are if prices spike.
Why Millions May Drop ACA Coverage
The enhanced premium subsidies introduced by the American Rescue Plan Act significantly reduced ACA marketplace premiums for millions of enrollees. Many people who previously couldn’t afford marketplace coverage were suddenly able to enroll — and did.
If those enhanced subsidies expire or are reduced, the same people who enrolled would face premium increases they can no longer afford — and many would drop ACA coverage entirely. According to Kaiser Family Foundation, millions of enrollees could lose coverage if enhanced subsidies end.
The Market Stability Problem
When healthier, lower-income people drop ACA coverage because they can no longer afford it, the remaining pool of enrollees skews sicker and older. This drives up costs for insurers — who then raise premiums for everyone still enrolled.
This is the “adverse selection spiral” that insurance market economists worry about: coverage becomes unaffordable, healthy people leave, costs rise, more people leave, costs rise further.
What Arizona Residents Should Do Now
If you’re currently on an ACA plan in Arizona and concerned about rising costs, here are your options:
Check your subsidy eligibility — income changes could mean larger subsidies than you currently receive
Compare off-exchange plans — if you earn too much for meaningful subsidies, a private PPO may cost less
Explore short-term medical plans — for healthy individuals between jobs or waiting for open enrollment
Contact a local broker — an independent broker can compare all options at no extra cost to you
Free Help Comparing Arizona Health Insurance Options
I’m Andy Orlikoff, an independent health insurance broker in Surprise, AZ. I help Arizona residents find affordable health coverage — whether that’s an ACA marketplace plan, a private PPO, or a short-term plan. My help is free. Your premium is the same whether you use a broker or go direct.
The federal government’s approach to Medicare Advantage payment rates has become a major issue for Arizona seniors. Proposed flat funding rates — where the government pays insurers a fixed amount regardless of rising healthcare costs — could trigger significant changes to Medicare Advantage plans starting in 2027. Here’s what’s happening and what it could mean for your coverage.
What Are Medicare Advantage Payment Rates?
The federal government pays private insurance companies a set amount per enrollee to administer Medicare Advantage plans. These Medicare Advantage payment rates are set annually by the Centers for Medicare and Medicaid Services (CMS). The payment amount affects how much margin insurers have — which in turn affects the benefits, networks, and premiums they can offer enrollees.
According to CMS, the 2027 advance notice proposed payment rates that alarmed many health insurers — at 0.09% growth, far below what insurers said they needed to keep pace with rising healthcare costs.
Why Flat Medicare Advantage Payment Rates Are a Problem
When Medicare Advantage payment rates don’t keep up with actual healthcare cost inflation, insurers face a choice: absorb losses, reduce benefits, raise copays, or exit markets. We’ve already seen this pattern play out:
UnitedHealthcare contracted its Medicare Advantage enrollment by over 1 million members
Humana, CVS Health’s Aetna, and Elevance Health pulled back from certain markets
Major insurers have reduced extra benefits like dental, vision, and OTC allowances
Some plans have increased copays and narrowed provider networks
If flat payment rates become the norm, these trends are likely to accelerate through 2027 and beyond.
What This Means for Arizona Medicare Advantage Enrollees
If you’re currently on a Medicare Advantage plan in Arizona, here’s the practical risk:
Your plan’s benefits could be reduced at the next Annual Enrollment Period
Your doctors or hospitals could leave the network
Your plan could exit the Arizona market entirely, forcing you to find a new plan
Copays and out-of-pocket maximums could increase
This isn’t speculation — it happened to over 1 in 10 Medicare Advantage members in 2026, who were forced off their plans when insurers withdrew from markets.
Why Medicare Supplement Plans Are Not Affected
This is a critical distinction. Medicare Advantage payment rates set by the government affect Medicare Advantage plans directly. Medicare Supplement (Medigap) Plan G operates completely differently.
Medigap plans work alongside Original Medicare. They don’t depend on government payment negotiations with private insurers. The benefits are standardized by federal law, your coverage doesn’t change annually, and your doctors don’t leave a “network” because there is no network. Plan G works with any doctor who accepts Medicare — and that’s the vast majority of physicians in Arizona.
Is This a Good Time to Reconsider Medicare Advantage?
If you’re still in your Medigap open enrollment window — the 6 months after you first enroll in Medicare Part B — you can switch to a Medicare Supplement plan without medical underwriting. That window is the most important decision point in your Medicare journey.
If you’ve already been on Medicare Advantage for more than a year, switching to Medigap may require medical underwriting. That means insurance companies can review your health history before approving you. It’s not impossible, but it’s harder — which is why acting early matters.
Questions About Your Medicare Options in Arizona?
I’m Andy Orlikoff, an independent Medicare broker in Surprise, AZ. I don’t sell Medicare Advantage. I help Arizona seniors understand how Medicare Advantage payment rates and policy changes could affect their coverage — and whether a Medicare Supplement plan is a better fit for their situation.
A federal Inspector General’s report has raised serious questions about Medicare Advantage plan problems that affect millions of seniors. The report found that many Medicare Advantage plans have significant gaps in behavioral health coverage — and that some provider directories list doctors who don’t actually accept the plan. Here’s what the report found and what it means for Arizona seniors.
What the Inspector General’s Report Found
The U.S. Department of Health and Human Services Office of Inspector General conducted an investigation into Medicare Advantage plan problems with behavioral health coverage. The findings were troubling:
The majority of Medicare Advantage plans had “limited networks” of behavioral health providers
Many of the providers listed in plan directories were “ghost providers” — they appeared to be in-network but did not actually provide services to plan enrollees
On average, there were fewer than five active behavioral healthcare providers per 1,000 enrollees in Medicare Advantage plans
The report concluded that seniors enrolled in Medicare Advantage plans could face serious difficulty accessing mental health and substance abuse treatment — even when their plan technically showed these services as “covered.”
Why Medicare Advantage Plan Problems With Provider Networks Are Common
This isn’t the first report to flag Medicare Advantage plan problems with provider directories. The core issue is that Medicare Advantage plans are required to maintain a provider network — but the accuracy of those networks is difficult to verify and monitor.
Ghost providers are a well-documented issue. A provider may have agreed to join a network years ago and never updated their status. The plan continues to list them. A patient calls to make an appointment and discovers the doctor hasn’t accepted that plan in years — or doesn’t take new patients at all.
For behavioral health specifically, this creates a serious access problem. Mental health and substance abuse treatment often require ongoing appointments. Finding a new provider — especially one accepting new Medicare Advantage patients — can take months.
How Original Medicare Handles Behavioral Health Differently
Original Medicare takes a fundamentally different approach. Rather than requiring you to stay in a network, Medicare Part B covers mental health services — including outpatient therapy, psychiatry, and substance abuse treatment — from any provider who accepts Medicare. That’s the vast majority of licensed therapists and psychiatrists in Arizona.
With a Medicare Supplement Plan G, your share of those costs is zero after the Part B deductible. No networks, no provider directories to verify, no ghost providers.
What Arizona Seniors Should Know About Medicare Advantage Plan Problems
If you’re currently on a Medicare Advantage plan in Arizona and you need mental health or behavioral health services, there are a few practical steps:
Call the provider directly — don’t assume the directory is current
Ask explicitly: “Are you currently accepting new patients on [plan name]?”
If you’re denied coverage, file a formal appeal — you have the right to do so
Contact your State Health Insurance Assistance Program (SHIP) at AZDES.gov/AZSHIP for free counseling
If you’re approaching 65 or still in your Medigap open enrollment window, this is one more reason to consider whether Medicare Advantage is the right choice for your situation.
Questions About Your Medicare Coverage Options?
I’m Andy Orlikoff, an independent Medicare broker in Surprise, AZ. I don’t sell Medicare Advantage. After 20+ years watching these Medicare Advantage plan problems affect Arizona seniors, I help clients choose coverage that works when they need it most.
If you’ve spent the last year realizing that Medicare Advantage isn’t working for you — prior authorization denials, limited networks, surprise bills — you’re not alone. Thousands of Arizona seniors make the switch back to Original Medicare every year. In this guide, you’ll learn exactly how to switch from Medicare Advantage to Original Medicare, what windows are available, and what to watch out for.
Why People Switch from Medicare Advantage to Original Medicare
The most common reasons I hear from clients who want to switch from Medicare Advantage to Original Medicare:
Their doctor left the plan’s network
Prior authorization delays for procedures or specialists
Moving to a different part of Arizona or another state
Wanting access to Mayo Clinic or a major specialty hospital
High out-of-pocket costs after a serious illness
The plan’s benefits changed significantly at renewal
When Can You Switch from Medicare Advantage to Original Medicare?
There are two main windows to switch from Medicare Advantage to Original Medicare. Missing these windows means waiting until the next opportunity.
Medicare Advantage Open Enrollment Period (MA OEP)
January 1 – March 31 every year. During this window you can switch from one Medicare Advantage plan to another, or drop Medicare Advantage entirely and return to Original Medicare. Coverage changes take effect the first of the following month.
Annual Enrollment Period (AEP)
October 15 – December 7 every year. This is the main Medicare enrollment window. You can drop your Medicare Advantage plan and return to Original Medicare, with changes taking effect January 1. According to Medicare.gov, this is the primary window for making coverage changes.
The One-Way Door Problem: Medical Underwriting
Here’s the critical issue most people don’t know about when they try to switch from Medicare Advantage to Original Medicare: returning to Original Medicare is only half the equation.
Once you’re back on Original Medicare, you’ll want a Medicare Supplement (Medigap) Plan G to cover your out-of-pocket costs. But outside of your original 6-month Medigap open enrollment window, insurance companies can use medical underwriting — meaning they can deny you coverage or charge higher premiums based on your health history.
This is why I always tell clients: if you’re on Medicare Advantage and thinking about switching, do it sooner rather than later. The longer you wait, the more your health may change, and the harder it becomes to qualify for Medigap.
Special Enrollment Periods for Switching
In some situations you may qualify for a Special Enrollment Period (SEP) to switch from Medicare Advantage to Original Medicare outside the standard windows:
You moved out of your plan’s service area
Your plan is leaving the Medicare program
You qualify for Extra Help (Low Income Subsidy)
You were misled by your plan or agent
The Social Security Administration and Medicare handle these situations case by case. If you think you qualify, act quickly — SEP windows are typically 60 days.
Step-by-Step: How to Switch Back to Original Medicare
Confirm you’re in an eligible enrollment window (MA OEP, AEP, or SEP)
Contact your Medicare Advantage plan to disenroll — call the number on your plan card
Confirm your return to Original Medicare Parts A and B
Apply for a Medicare Supplement (Medigap) plan — do this simultaneously if possible
Sign up for a Part D prescription drug plan if you need one
Ready to Switch? I Can Help
I’m Andy Orlikoff, an independent Medicare broker in Surprise, AZ. I don’t sell Medicare Advantage — and I help Arizona seniors navigate the process to switch from Medicare Advantage to Original Medicare and get enrolled in the right Medigap plan. My help costs you nothing extra.
