Grand Junction · My plan is going away
Does Prior Authorization Carry Over to a New Medicare Plan?
Yes — for at least 90 days, by federal regulation, and that is exactly the question a non-renewal letter raises for anyone in the middle of chemotherapy, radiation, a joint replacement or rehab. Here is what the rule says, what it does not, and how to use the window from a Mesa County address.
The bottom line
- The rule is 42 CFR § 422.112(b)(8). A new Medicare Advantage plan "must not disrupt or require reauthorization for an active course of treatment for new plan enrollees for a period of at least 90 days."
- Out-of-network counts. The transition applies "even if the service is furnished by an out-of-network provider." Cost-sharing during the window is a separate question to ask the plan.
- Your current approval is not a fixed number of visits. An approval "must be valid for as long as medically necessary to avoid disruptions in care."
- It is a bridge. After day 90 the new plan's own rules apply — on 2026 clocks of 72 hours expedited and seven calendar days standard, with a written reason for any denial.
- Original Medicare is the other door. It rarely requires prior authorization, and a discontinued plan opens guaranteed-issue Medigap rights in Colorado. Doing nothing puts you there on January 1 — with no drug plan.
- The calendar: pick during October 15 – December 7 for a January 1 start, or use the non-renewal Special Enrollment Period, December 8 through the last day in February.
The letter that says your plan is being discontinued reads differently when there is a treatment calendar on the refrigerator next to it. Most of what we have written this month about a plan ending — the first steps, the doctors, the prescriptions, the Medigap window — assumes you have the fall to think. If you are six infusions into twelve, or a week out from a knee replacement St. Mary's already approved, you do not want a list of options. You want to know whether the approval you fought for in August survives January 1. It does, for a while, and the "for a while" is written into federal regulation.
What the rule actually says
Since the 2024 contract year, every Medicare Advantage coordinated-care plan has been bound by 42 CFR § 422.112(b)(8). It sets three requirements for "enrollees undergoing an active course of treatment," and two of them are about you changing plans.
| What the regulation requires | The language |
|---|---|
| Approval stays valid for the course | An approved prior authorization for a course of treatment "must be valid for as long as medically necessary to avoid disruptions in care" — not for a fixed number of visits the plan picks. |
| A 90-day floor when you change plans | A new Medicare Advantage plan "must not disrupt or require reauthorization for an active course of treatment for new plan enrollees for a period of at least 90 days." |
| Out-of-network does not break it | The transition applies "even if the service is furnished by an out-of-network provider." Cost-sharing is a separate question — ask the plan how it bills out-of-network care during the window. |
| It is a bridge, not the whole road | After day 90 the new plan may apply its own prior authorization rules to what remains. The rule buys time to move the approval, not a waiver for the year. |
Source: 42 CFR § 422.112 — Access to services (eCFR), paragraph (b)(8); text confirmed against the Cornell LII mirror. The CMS fact sheet for the rule that added it describes "a minimum 90-day transition period when an enrollee currently undergoing treatment switches to a new MA plan, during which the new MA plan may not require prior authorization for the active course of treatment."
The sentence I would underline is the last one in the regulation's own words: "This includes enrollees new to a plan and enrollees new to Medicare." A person whose plan was discontinued and who picks a different carrier for 2027 is an enrollee new to a plan. There is no carve-out for "your old plan left the county" — if anything, that is the situation the rule was written for.
What counts as an "active course of treatment"
The regulation defines both halves. A course of treatment is "a prescribed order or ordered course of treatment for a specific individual with a specific condition [that] is outlined and decided upon ahead of time with the patient and provider," and it "may but is not required to be part of a treatment plan." An active course of treatment is one "in which a patient is actively seeing the provider and following the course of treatment."
In plain terms: a chemotherapy regimen with a set number of cycles, a radiation schedule, a course of physical therapy after surgery, ongoing infusions for a rheumatologic condition, a dialysis schedule, the pre-operative work-up and the surgery it leads to — those are courses of treatment that were decided ahead of time with your doctor, and if you are showing up for them, they are active. A referral you have not used yet, or a procedure your doctor mentioned but has not ordered, is a weaker case. The test is whether the plan of care already exists on paper and whether you are following it.
What the 90 days do not do
Three limits, because the rule is narrower than the relief people feel when they read it.
- It does not run for the whole treatment. The floor is 90 days from your effective date with the new plan — January 1 through the end of March for a January 1 start. Cycles that fall after that are subject to the new plan's own prior authorization policy. The window is there to get the new approval in place while the old one still carries you.
- It is not a network guarantee. The plan may not disrupt the course "even if the service is furnished by an out-of-network provider" — but the regulation is about authorization, not about what you pay. On an HMO, out-of-network care outside the transition is generally not covered at all; on a PPO it is covered at a higher share. Ask the new plan, in writing, how the transition care is billed. Better still, pick a plan whose 2027 directory includes the treating group and the hospital, which is the point of the network post.
- It is not the drug rule. Prescriptions run under Part D, which has its own transition-fill protection. If your treatment includes an oral chemotherapy agent or a specialty drug, that check is separate and we walked through it in the formulary post.
The January 1 doors, seen from the middle of a treatment
A discontinued plan leaves you the same four outcomes it leaves everyone; what changes is which one protects an in-progress course of care. Medicare.gov is explicit about the default: "You'll be enrolled in Original Medicare if you don't join another Medicare Advantage Plan before your current plan ends."
| January 1 outcome | What happens to the treatment | What to check |
|---|---|---|
| Pick a new Medicare Advantage plan | 90-day transition: no reauthorization for the active course, in or out of network. Then the new plan's rules. | Check the hospital and the treating group against the 2027 directory before you enroll. |
| Original Medicare plus Medigap | Original Medicare applies prior authorization to a short list of items; a course of chemotherapy, radiation or rehab generally proceeds on the doctor's order. | Any provider that takes Medicare. Guaranteed-issue Medigap rights come with the non-renewal — see the linked post. |
| Original Medicare with a drug plan only | Same as above for the treatment itself. | No yearly out-of-pocket ceiling on the 20% — the risk that matters most mid-treatment. |
| Do nothing | You land in Original Medicare on January 1 with no drug plan. The treatment is covered; the prescriptions around it are not. | No network and no ceiling — and the Part D penalty clock starts. |
Sources: 42 CFR § 422.112(b)(8) for the transition; Medicare.gov Special Enrollment Periods for the default and the December 8 – the last day in February window. Colorado Medigap guaranteed-issue rights are covered in the Medigap post.
Two of those rows deserve a sentence each. The Original Medicare door is unusually strong mid-treatment, because Original Medicare applies prior authorization to a short list of items and outpatient services rather than to courses of care — but it only works with a Medigap policy behind it, since Original Medicare alone has no yearly cap on your 20%, and a discontinued plan is one of the few events that lets a Coloradan buy Medigap without health questions. The "do nothing" row is the one to avoid: the treatment itself is covered on January 1, but the prescriptions around it are not, and there is no ceiling on the bill.
How to use the window, in order
- Get the current approvals in writing now. Ask the treating office for a copy of every active prior authorization — the service, the number of cycles or visits, the dates. That paper is what you will hand the new plan on day one.
- Confirm the course of treatment is documented as a course. A written plan of care with cycles and dates is what the regulation protects. If the schedule lives only in a conversation, ask for it on paper.
- Check the treating group and the hospital against the 2027 directory before you enroll — St. Mary's, Community Hospital, the infusion center, the physical therapy clinic. In-network care after day 90 is the goal; the transition is the backstop. The 2027 directories publish when the plans do, on October 1 — not before.
- On your effective date, have the office file for continuation with the new plan. Do not wait for day 90. The 2026 decision clocks — 72 hours expedited, seven calendar days standard — are short enough that a January request is answered in January.
- If the new plan denies anything, appeal it the same week. A denial must now come with a specific reason. The first appeal goes back to the plan; if the plan affirms, it forwards the case to an independent reviewer. Medicare.gov's appeals page has the steps, and our prior authorization post has the 2024 overturn rates.
- Handle the drugs on a separate list. Oral chemotherapy, anti-nausea, specialty injectables — check each against the new plan's formulary and tier, and know the transition-fill rule.
Why this lands in Mesa County
Grand Junction is the regional medical center for the Western Slope, and the courses of treatment that make this rule matter — oncology, cardiac rehab, joint replacement, dialysis — mostly run through two buildings: Intermountain Health St. Mary's Regional Hospital and Community Hospital, per the CMS hospital file. Per CDC PLACES, 5.2% of Mesa County adults live with coronary heart disease and 8.1% with diabetes — the conditions behind a good share of the in-progress care a non-renewal letter interrupts. People drive in from Delta, Montrose and Rifle for these treatments, which means a plan's 2027 directory has to be read for the Grand Junction facility, not just the hometown clinic.
What we cannot tell you in September is which 2027 plans list which oncologists, or what any plan's premium or out-of-pocket maximum will be. That data is published October 1. What we can tell you is that the 90-day rule does not depend on it.
What I would do this fall
If you are mid-treatment and your plan is ending, I would gather the approvals this month, wait for the October 1 directories, and then choose during Annual Enrollment so the new coverage starts January 1 with the full 90 days in front of it. I would treat the December 8 – the last day in February Special Enrollment Period as the safety net it is — an effective date in February means a treatment gap in January, which is the one thing the rule cannot fix. And I would take the whole file to one meeting, because a plan change in the middle of a course of care is a coordination job, not a shopping job.
How we know all this: the Medicare On Main Data Desk frames every article with public data. The 90-day transition period, the "must not disrupt or require reauthorization" language, the out-of-network clause, the "enrollees new to a plan and enrollees new to Medicare" sentence, the "valid for as long as medically necessary" standard and both definitions are quoted from 42 CFR § 422.112(b)(8) on the eCFR, confirmed against the Cornell Legal Information Institute mirror; the CMS fact sheet for the CY2024 Medicare Advantage and Part D final rule (CMS-4201-F) describes the same transition. The 72 hours and seven calendar days decision timeframes and the 2026 denial-reason requirement are from the CMS fact sheet for the Interoperability and Prior Authorization final rule (CMS-0057-F). The January 1 default and the December 8 – the last day in February Special Enrollment Period are quoted from Medicare.gov's Special Enrollment Periods page; the non-renewal notice description is from Medicare.gov's Plan Non-Renewal Notice page. Hospital names are from the CMS Hospital General Information dataset; county chronic-condition prevalence is CDC PLACES County Data 2023. No 2027 plan, premium, star rating, carrier or network detail is stated, because CMS has not published it. No carrier is endorsed or criticized; "the plan is being discontinued" is the whole of what a non-renewal means. This is education, not medical, legal or enrollment advice — confirm your own approvals with your treating office and your plan, and your options with a licensed agent or Medicare.gov.
Frequently asked questions
Does prior authorization carry over to a new Medicare Advantage plan?
For an active course of treatment, yes — for at least 90 days. Federal regulation 42 CFR § 422.112(b)(8) requires a Medicare Advantage organization to provide "a minimum 90-day transition period for any active course(s) of treatment when an enrollee has enrolled in an MA plan after starting a course of treatment," and says the plan "must not disrupt or require reauthorization for an active course of treatment for new plan enrollees for a period of at least 90 days." The rule applies "even if the service is furnished by an out-of-network provider," and it covers "enrollees new to a plan and enrollees new to Medicare." It has been in force since the 2024 contract year.
What happens to my prior authorization if I switch Medicare Advantage plans?
The new plan has to honor the course of treatment you are in the middle of for at least 90 days from your effective date, without making your doctor re-apply. After that window, the new plan may apply its own prior authorization policy to whatever remains, and those requests run on the 2026 clocks CMS set in its interoperability rule: a decision within 72 hours for an expedited request and seven calendar days for a standard one, with a specific reason if it denies. The practical move is to have the new plan's authorization in hand before day 90, not after.
How long does a Medicare Advantage prior authorization last?
Under the same regulation, an approval "for a course of treatment must be valid for as long as medically necessary to avoid disruptions in care, in accordance with applicable coverage criteria, the individual patient's medical history, and the treating provider's recommendation." That is the rule for the plan you are in now. A plan you are leaving on December 31 cannot bind the plan you join on January 1 — that is what the 90-day transition is for.
Can a Medicare Advantage plan deny a treatment I already started?
Not by making you re-authorize it in the first 90 days after you join, and not by cutting an approved course short while it is medically necessary. Outside those protections, a plan can issue a denial, and the answer is to appeal: Medicare Advantage denials go first to the plan for reconsideration and, if the plan affirms, on to an independent review entity. Bring the treating provider's notes. We covered the appeal ladder and the 2024 overturn rates in our prior authorization post.
Do I need prior authorization if I go back to Original Medicare?
Rarely. Original Medicare applies prior authorization to a narrow list of items and outpatient services, so an ongoing course of chemotherapy, radiation or post-surgical rehab generally proceeds on the doctor's order. A discontinued plan also opens guaranteed-issue Medigap rights in Colorado, which is what makes the Original Medicare door usable mid-treatment — without a Medigap policy there is no yearly cap on the 20% coinsurance. If you do nothing, Medicare.gov says "you'll be enrolled in Original Medicare" when your plan ends, but with no drug coverage, so the prescriptions around the treatment become the problem.
Does Medicare On Main charge for help if my plan is discontinued?
No. Brian Penner is an independent licensed Medicare advisor with 22+ years of experience, paid by the carriers, not by you. Our Grand Junction office is at 627 24 1/2 Rd Ste H — call (970) 644-6954. We do not offer every plan available in your area, and we'll tell you plainly when Medicare.gov, 1-800-MEDICARE or your treating team's financial counselor is the right next call.
Sources
- 42 CFR § 422.112 — Access to services (eCFR) — paragraph (b)(8): the 90-day transition, the validity standard, both definitions.
- 42 CFR § 422.112 — Cornell Legal Information Institute mirror — the same text, used to confirm the quotation.
- CMS — 2024 Medicare Advantage and Part D Final Rule (CMS-4201-F) fact sheet — CMS's description of the rule that added the transition period.
- CMS — Interoperability and Prior Authorization Final Rule (CMS-0057-F) fact sheet — the 72 hours / seven calendar days decision clocks and the 2026 denial-reason rule.
- Medicare.gov — Special Enrollment Periods — the January 1 default and the December 8 – the last day in February window.
- Medicare.gov — Plan Non-Renewal Notice — what the letter is.
- Medicare.gov — Open Enrollment (October 15 – December 7) — the October 15 – December 7 window.
- Medicare.gov — How do I file an appeal? — the appeal steps if the new plan denies.
- CMS Hospital General Information (data.cms.gov) · CDC PLACES, 2023 — via the Medicare On Main Data Desk — Mesa County hospitals and chronic-condition prevalence.
