This issue brief explores the role of prior authorization within the Medicaid system, focusing on its regulatory framework and impacts. Prior authorization requires health care providers to obtain approval from payers before delivering certain medical services, items, or medications. While prior authorization can reduce health care costs, it may limit beneficiary access to care through delays and denials of needed medical services, and may place burdens on beneficiaries and providers. Recent federal and state-level regulations aim to address these issues by improving the efficiency and transparency of prior authorization procedures.
This brief provides an overview of federal regulations governing prior authorization and describes its impact on patient safety, program integrity, costs, and access. It also addresses key issues related to prior authorization for Medicaid providers and beneficiaries.
