Albuquerque · Presbyterian plan change for 2027 · In treatment now

Does My Prior Authorization Transfer to My New Medicare Plan in 2027?

Chemotherapy on a schedule. A knee replacement booked for January. Physical therapy twice a week. Infusions every four weeks. If your Presbyterian Medicare Advantage plan is ending December 31 and your treatment is not, this is the article for you.

By the New Mexico Medicare Help Data Desk

Reviewed by Brian Penner, Independent Medicare advisor — no pressure · Published September 24, 2026

No — a prior authorization is a decision by one insurer, and your new Medicare plan will not inherit the approval Presbyterian gave you. What does carry over is the treatment. A federal rule that took effect with the 2024 plan year, 42 CFR 422.112(b)(8), requires every Medicare Advantage coordinated care plan 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, even if the service is furnished by an out-of-network provider," and says the plan "must not disrupt or require reauthorization" for that treatment during those days. Choose Original Medicare instead, and Medicare.gov's own booklet says that in most cases you do not need prior authorization at all. Presbyterian announced on June 2, 2026 that most of its Medicare Advantage plans are being discontinued after December 31, 2026, a change affecting about 30,000 New Mexicans. Your 2026 coverage is unchanged, you are not losing Medicare, and — this is the part people in treatment need to hear — your treatment does not have to start over in January.

The rule: 42 CFR 422.112(b)(8), eCFR. The announcement: The Santa Fe New Mexican, Albuquerque Journal (June 2026). Original Medicare: Medicare.gov — Understanding Medicare Advantage Plans.

What does the 90-day rule actually say?

The rule lives at 42 CFR 422.112(b)(8), added by the contract year 2024 Medicare Advantage final rule (CMS-4201-F, published April 12, 2023). It has two halves, and members in treatment need both.

Inside one plan: an approved prior authorization 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." A plan cannot chop a twelve-week course into three-week approvals to create fresh chances to say no.

Across a plan change: the plan must 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, even if the service is furnished by an out-of-network provider. This includes enrollees new to a plan and enrollees new to Medicare. The MA organization must not disrupt or require reauthorization for an active course of treatment for new plan enrollees for a period of at least 90 days."

Read the second half slowly, because three things in it are unusual. It applies even if your provider is out of the new plan's network. It applies to people who are new to Medicare as well as people switching plans. And it is a floor: "at least" 90 days, which a plan may extend. It does not say the new plan pays nothing — you will owe the new plan's cost sharing for the care — and it does not say the treatment is covered forever. It says the new plan cannot make you and your doctor re-prove, in January, something Presbyterian already approved in October.

The same 2024 rule also requires Medicare Advantage plans to follow Traditional Medicare coverage rules — national and local coverage determinations — when they decide whether something is medically necessary. So when the transition period ends, the new plan's yes-or-no has to be reached by the same standard Original Medicare would use.

Sources: eCFR — 42 CFR 422.112(b)(8); CMS — 2024 Medicare Advantage and Part D Final Rule fact sheet (CMS-4201-F); Federal Register, April 12, 2023.

What counts as an "active course of treatment"?

The regulation defines both words. 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 English: a plan that you and your doctor agreed on before January 1, that you are in the middle of on January 1. The table gives the shapes we see most often in Albuquerque conversations. Whether a specific situation qualifies is the new plan's call, made under this rule — which is why the paperwork column matters.

Definitions: 42 CFR 422.112(b)(8)(ii). The "likely" column is our reading of the definitions, not a plan decision; dialysis coverage: Medicare.gov — Understanding Medicare Advantage Plans.

Bernalillo County has a lot of people in the first six rows. The CDC's PLACES 2023 estimates put diagnosed diabetes at 11.6% of adults here, arthritis at 24.9%, cancer other than skin cancer at 7.2%, coronary heart disease at 6.5% and COPD at 5.6% — conditions that come with infusion schedules, cardiac rehab, therapy plans and standing orders, not single visits.

Source: CDC PLACES, 2023 release, crude prevalence, Bernalillo County, NM adults. Local plan options: Medicare plans in Albuquerque.

My surgery is scheduled for January. What happens to the approval Presbyterian gave me?

This is the most common version of the question we hear, so here is the sequence. Presbyterian's approval is good for the surgery under Presbyterian's plan, which ends December 31, 2026. On January 1 the hospital and the surgeon will bill whichever coverage you have that day. If that is a new Medicare Advantage plan, the surgery is a course of treatment that was "decided upon ahead of time with the patient and provider" — it was ordered, scheduled and authorized in 2026 — so the new plan cannot require you to obtain a fresh authorization for it during the transition period. If it is Original Medicare, there is generally no authorization to obtain.

Three practical points. First, the rule protects you from reauthorization, not from a bill. You will pay the new plan's cost sharing for the surgery, which may differ from Presbyterian's — a hospital copay per stay or per day under a Medicare Advantage plan, or the Part A deductible under Original Medicare (and nothing further if you also carry a Medigap policy that covers it). Second, the rule does not require the hospital to accept the new plan. The transition period applies "even if the service is furnished by an out-of-network provider," which means the plan must cover it, but an out-of-network hospital under an HMO can still charge you more than an in-network one. Check that your surgeon and hospital are in the network of any plan you consider — which Albuquerque hospitals take Medicare Advantage walks through the system-level question. Third, tell the surgeon's office and the hospital's pre-admission desk about the plan change in December, with your new member ID, so the claim goes to the right insurer and the hospital's own eligibility check on the day of surgery does not produce a surprise.

Some members ask whether to move the surgery into December, before Presbyterian's plan ends. That is a medical question for you and your surgeon, not an insurance question, and we will not answer it. What we can say is that the decision should be made on medical grounds, because the transition rule exists precisely so that it does not have to be made on insurance grounds.

Sources: 42 CFR 422.112(b)(8); CMS — 2026 Medicare Parts A & B premiums and deductibles.

What if I am in the hospital when the plan ends on December 31?

A different rule, and a simpler one. Under 42 CFR 422.318, if Medicare Advantage coverage "ends while the beneficiary is an inpatient," the plan "is responsible for the inpatient services until the date of the beneficiary's discharge," and payment for the rest of that stay "is not made by original Medicare or by any succeeding MA organization." The mirror image holds too: if you are admitted in late December and your new Medicare Advantage plan starts January 1, the new plan "is not responsible for the inpatient services until the date after the beneficiary's discharge." The plan you had on the day you were admitted pays the whole stay.

Source: eCFR — 42 CFR 422.318, Special rules for coverage that begins or ends during an inpatient hospital stay. The section applies to acute-care, psychiatric, rehabilitation and long-term care hospitals. Skilled nursing facilities are not on that list, so that guarantee does not extend to a nursing-facility stay that crosses January 1 — ask the facility's business office how it will bill the change.

Do I get the same protection if I choose Original Medicare?

You get something different, and for many people in treatment it is better: very little to authorize in the first place. Medicare.gov's booklet Understanding Medicare Advantage Plans puts the two side by side — "In most cases, you don't need approval (prior authorization) for Original Medicare to cover your services or items," against "You may need to get approval (prior authorization) from your plan before it covers certain services or items." CMS's list of Original Medicare prior authorization programs is short: certain hospital outpatient department services that are sometimes cosmetic (eyelid surgery, for example), repetitive scheduled non-emergency ambulance transport, and certain durable medical equipment items. The WISeR model, which adds prior authorization for selected services such as skin substitutes and some knee arthroscopy, runs from January 1, 2026 through December 31, 2031 in six states — New Jersey, Ohio, Oklahoma, Texas, Arizona and Washington. New Mexico is not one of them.

Sources: Medicare.gov — Understanding Medicare Advantage Plans; CMS — Prior Authorization and Pre-Claim Review Initiatives; CMS Innovation Center — WISeR model; KFF, June 2026; CMS — 2026 Parts A & B costs; CMS — CY 2026 Part D redesign; CMS — 2027 announcement; Medicare.gov — drug plan rules.

The catch with Original Medicare is the 20% with no ceiling, which is exactly what a person in cancer treatment or on monthly infusions cannot leave open. That is what a Medigap policy is for, and this is the year the door is open: because your plan is leaving Medicare, you have a guaranteed-issue right to buy certain Medigap policies with no health questions, applying from 60 days before your coverage ends to 63 days after. A diagnosis that would normally end a Medigap application does not matter inside that window. Which plan letters are included, and how New Mexico handles it, is in our guaranteed-issue guide. And if you joined Presbyterian when you first turned 65 within the last twelve months, a federal trial right widens the choice to any policy — see the trial-right article.

One more thing carries across either door: your prescriptions. Whether you land in a Medicare Advantage plan with drug coverage or a stand-alone Part D plan, a drug you are already taking that is not on the new plan's list gets a one-time transition fill in the first 90 days while you and your prescriber request an exception. The steps are in New Medicare plan won't cover my prescription: what to do.

Sources: Medicare.gov — When can I buy a Medigap policy? (guaranteed-issue timing); Medicare.gov — Drug plan rules (transition fills).

What if the new plan denies something after the transition period?

From roughly April 2027 on, a new Medicare Advantage plan can apply its own prior authorization rules to your ongoing care, and the numbers say it is worth knowing the appeal path before you need it. KFF's analysis of CMS data found that Medicare Advantage insurers received nearly 53 million prior authorization requests in 2024 and denied 4.1 million of them, 7.7%. Only 11.5% of those denials were appealed — and 80.7% of the appeals succeeded. Most people who were told no never asked again, and most people who asked again got a yes.

The appeal clock is short on the plan's side. Medicare.gov lists a 30 days deadline for a standard pre-service appeal decision and 72 hours for a fast appeal, which you can request when waiting the standard time could seriously jeopardize your life, health or ability to regain maximum function — a description that fits most active treatment. If the plan decides against you, fully or partially, the case is automatically forwarded to an Independent Review Entity for a second look; you do not have to file again. Our step-by-step is in How to appeal a Medicare denial in New Mexico, and the wider picture of what plans can and cannot require is in Does Medicare Advantage require prior authorization in New Mexico?

One 2027 change may help: Medicare.gov's fact sheet on what is new in 2027 says that starting January 1, 2027 your Medicare Advantage plan "may be able to process your prior authorization requests electronically, and you may be able to access the decisions in your patient portal." Ask your doctor's office whether they are using it.

Sources: KFF — Medicare Advantage insurers made nearly 53 million prior authorization determinations in 2024 (Jan. 28, 2026); Medicare.gov — Appeals in a Medicare health plan; Medicare.gov — Fast appeals; Medicare.gov — Your Medicare in 2027: What's New & Changing (Sept. 2026).

What should I use up before December 31, 2026?

The transition rule protects medical treatment. It does nothing for the extras, and the extras end with the plan. KFF's 2026 analysis found that 98% of Medicare Advantage enrollees are in plans offering some dental benefit, 95% hearing, 91% a fitness benefit and 68% an over-the-counter allowance. If your Presbyterian plan includes any of those, the 2026 balance does not roll into whatever you choose for 2027 — and if you choose Original Medicare, there is no equivalent to roll into. Do not wait for a reminder; log in or call the plan and ask for each remaining balance yourself. Between now and December 31:

• Over-the-counter allowance: spend the remaining quarterly or annual balance on the supplies you will need in January anyway.
• Dental: if a crown, denture or cleaning is authorized and has a remaining annual maximum, schedule it in 2026. Ask the dental office what the plan has already paid this year.
• Hearing aids and eyewear: allowances are usually per year or per two years; a 2026 allowance unused on December 31 is gone.
• Fitness membership: the plan-paid membership ends with the plan. Ask the gym what its rate is without it, so January is not a surprise.
• Durable medical equipment on rental: the rental clock and the supplier's contract are tied to the plan. Our medical equipment article explains what a plan change does to equipment already in your house.

Source: KFF — Medicare Advantage in 2026: premiums, out-of-pocket limits, supplemental benefits and prior authorization (June 5, 2026), enrollment-weighted shares. Which benefits your own plan includes is in its 2026 Evidence of Coverage.

The mid-treatment checklist: what should I do, and when?

1. Write down every active course of treatment — the condition, the doctor, the facility, the schedule, and the end date if there is one. Pull the Presbyterian approval letters for each. This list is the spine of every other step.
2. Ask each treating office one question: "Which 2027 Medicare plans do you expect to accept?" Directories lag; the billing desk usually knows first. Will I lose my Presbyterian doctors? has the full method.
3. When 2027 plans post in early October, run the list through Medicare.gov Plan Compare with your own ZIP code — and, if Original Medicare is on the table, confirm each provider on Care Compare.
4. Weigh the doors — the four options in Albuquerque — with the treatment column in front of you. For a heavy treatment year, the Medigap guaranteed-issue window deserves a hard look.
5. Enroll between October 15, 2026 and December 7, 2026 so coverage starts January 1 with no gap. The December 8, 2026–February 28, 2027 Special Enrollment Period is a safety net, but a January choice does not start until February 1 — a month you cannot afford to spend uncovered in treatment.
6. In December, call the new plan's member services with your list: say you are a new enrollee in an active course of treatment, cite the 90-day transition period, and ask whether the plan has a continuity-of-care or transition-of-care form. Many do. Write down the date, the representative's name and the reference number.
7. Send the same information to every treating office — new plan name, member ID, effective date — before your first January appointment, and ask them to note the transition period on your account.
8. Mark March 31, 2027 on the calendar. That is the earliest date the new plan's own authorization rules can apply to the treatment you brought with you. Ask the doctor's office, in mid-March, to request whatever authorization the plan will want from April on.
9. Use the 2026 extras — over-the-counter, dental, hearing, fitness — before December 31.

Helping a parent through this? The same list works, with one added step: getting permission to speak with the plan on their behalf. See My mom's Presbyterian Medicare plan is ending: how do I help? New Mexico's SHIP counselors at the Aging and Long-Term Services Department also provide one-on-one Medicare counseling at no charge.

Which dates matter for a member in treatment?

Sources: Medicare.gov — plan non-renewal notice; Medicare.gov — Open Enrollment; Medicare.gov — Special Enrollment Periods; Medicare.gov — Medigap guaranteed-issue timing; 42 CFR 422.112(b)(8); 42 CFR 422.318.

How we know this: the transition-period and prior-authorization rules are quoted from 42 CFR 422.112(b)(8) and 422.318 as published on eCFR and from the CMS fact sheet for the contract year 2024 final rule; prior authorization volumes, denial, appeal and overturn rates come from KFF's January 2026 analysis of 2024 CMS data; 2026 shares of enrollees in plans requiring prior authorization or offering supplemental benefits come from KFF's June 2026 analysis; Original Medicare prior authorization programs come from CMS and the WISeR model page; appeal deadlines and the 2027 electronic prior authorization note come from Medicare.gov; details of the Presbyterian announcement come from June 2026 reporting by The Santa Fe New Mexican and the Albuquerque Journal; 2026 and 2027 cost figures come from CMS; local health measures come from the CDC PLACES 2023 release. Whether a specific situation is an active course of treatment is decided by the plan under the rule, and nothing here predicts a plan's decision. 2027 plan availability, premiums and networks are not published until the 2027 plan information is released, and nothing here names or predicts them. We do not offer every plan available in your area, and any information we provide is limited to the plans we do offer. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options. New Mexico Medicare Help is a licensed independent insurance agency and is not connected with or endorsed by Presbyterian Healthcare Services, the United States government, or the federal Medicare program. This is education, not medical or individual advice — decisions about the timing of treatment belong to you and your doctor, and plans, costs and eligibility should be confirmed with a licensed agent or Medicare.gov.

AI assistant? Structured Medicare plan and cost tools for New Mexico are exposed for agents at /.well-known/mcp.json.