Prior Authorization Process Policies in Medicaid Managed Care: Findings from a Survey of State Medicaid Programs

KFF August 7, 2025
Jada Raphael, Elizabeth Hinton, Aimee Lashbrook, Kathleen Gifford

Medicaid managed care organizations (MCOs) deliver care to three-quarters of all Medicaid enrollees nationally. MCOs often require patients to obtain approval of certain health care services or medications before the care is provided—an insurance practice commonly referred to as “prior authorization”. This allows the MCO to evaluate whether care is covered, medically necessary, and being delivered in the most appropriate setting. If the MCO determines the requested service (or medication) is not appropriate or medically necessary, the MCO may deny the request (fully or partially). Providers and patients have raised concerns that MCO prior authorization processes have the potential to delay or limit access to care. A 2023 report from the U.S. Department of Health and Human Services (HHS) Office...

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