Providing Solutions to Address Challenges with MA Plans

More than 34.1 million Americans were enrolled in a Medicare Advantage plan in 2025, accounting for 54% of all Medicare beneficiaries. We have seen enrollment in MA plans increase significantly over the past two decades, and the Congressional Budget Office projects that MA enrollment will continue to grow, potentially reaching 64% of eligible beneficiaries in the next 10 years.

When people choose an MA plan, they count on the plan they selected to provide the agreed-upon coverage for either current medical needs or those that may arise. While some MA plans fulfill their responsibility to promote strong patient care and access, others often do not. These plans primarily include several of the country’s largest commercial insurers covering millions of Medicare enrollees.

We see frequent stories of patients across the nation who report experiencing inappropriate barriers to the care they need, as their MA plans often use prior authorization requirements in ways that lead to dangerous delays in treatment, clinician burnout and waste in the health care system. While prior authorization can be a tool to help ensure patients receive coverage for their care, too often the practice has been misused by large commercial insurers serving MA beneficiaries.

A new KFF analysis found that MA insurers made nearly 53 million prior authorization determinations in 2024, an increase of more than 3 million from the previous year. At the same time, the report also found that MA insurers fully or partially denied 7.7% of prior authorization requests they received in 2024. However, when appealed, these initial denials were overturned in 81% of cases. The high overturn rate suggests that many initial prior authorization denials were not clinically justified and instead functioned as an administrative barrier for delaying or denying access to medically necessary care.

Behind the numbers are real people with real stories of being denied coverage for needed care and the negative impacts it has had on their health and lives.  MA plans are supposed to provide coverage for any care that a similar enrollee in Traditional Medicare would receive. However, providers and patients routinely report coverage denials for care that beneficiaries are entitled to, indicating that many MA plans frequently apply more restrictive coverage rules than Traditional Medicare.

The AHA has long advocated for strengthening federal oversight of MA programs to ensure beneficiary access to care, program integrity and the financial stability of Medicare overall. Recently we shared some modernization recommendations with the Centers for Medicare & Medicaid Services to help ensure that program rules and oversight mechanisms will better serve beneficiaries, providers and taxpayers.

Among other needed improvements are ensuring that MA plan reporting requirements are sufficiently robust to enable meaningful oversight and that the measures in the Star Ratings program best align quality incentives with meaningful outcomes and beneficiary protections.

We also continue to push for congressional action. Among other priorities, we are urging Congress to enact:

• The Improving Seniors’ Timely Access to Care Act (H.R.3514/S.1816), which requires use of standardized electronic authorization processes, increases transparency and sets faster decision timeframes for care.
• The Medicare Advantage Prompt Pay Act (H.R.5454/S.2879) to help ensure health care providers receive timely payment from MA plans for services provided to patients for medically necessary care, the delay of which is a major source of excess administrative costs in the system.
• Legislation to protect patient access to medically necessary post-acute care by mandating that insurers ensure adequate representation of post-acute care providers in networks and streamline prior authorization processes to avoid unnecessary delays.

Fortunately, not all insurers and MA plans behave the same way. Smaller, community-based regional plans and provider-led MA plans often work closely with stakeholders to deliver coordinated, high-quality coverage. Many operate within integrated delivery systems where insurers and clinicians design coverage rules together to support timely, well-coordinated care. As Congress examines ways to improve the health care system, these plans offer a clear model for achieving high-quality coverage without the costly, problematic practices seen among large commercial insurers.

Medicare Advantage plans can be complex, but the underlying agreement should be simple: Coverage will be there for you when you need it. Let’s make sure that assurance is honored as we work to advance health in our nation.