The Gist Healthcare Podcast Wednesday, February 4, 2026
Feb 4, 2026
A deep dive into a surge of prior authorization requests in Medicare Advantage and the patient delays caused by denials and low appeal rates. Coverage of a new six-year prior authorization pilot in traditional Medicare. Examination of declines in ACA marketplace enrollment, state-by-state shifts, and changes to tax credits. Brief coverage of two major hospital deal reshufflings and an upcoming big pharma investment tease.
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Spending Bill Ends Brief Shutdown
- The House passed a $1.2 trillion funding package to end a brief shutdown and fund HHS through September 30.
- Around 20 Democrats joined passage, and the lapse briefly affected hospital-at-home and telehealth waivers.
Prior Authorizations Surge In Medicare Advantage
- Medicare Advantage plans saw roughly 53 million prior authorization requests in 2024, reflecting growing utilization as MA enrollment rises.
- Prior authorizations caused delays and about 8% were partially or fully denied, suggesting access friction despite many denials later being overturned on appeal.
Denials Often Reversed On Appeal
- About 8% of MA prior authorization requests were denied and only 12% of those denials were challenged by enrollees.
- More than 80% of challenged denials were overturned, indicating approvals often follow initial denials after appeals.