Regulations & Policy

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Regulations & Policy

Learn about Medicare Advantage's impact on post acute from recent analysis & research, regulations, policy and news.

Congress Focuses on Reforming Medicare Advantage Prior Authorization

May 23, 2025

US Senate

Federal lawmakers urge CMS to increase oversight of MA plans, particularly those “inventing new strategies” like concurrent reviews, pre-payment audits, and payment integrity administrative reviews to delay or deny care…

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CMS Rolls Out Aggressive Strategy to Enhance and Accelerate Medicare Advantage Audits

May 21, 2025

The CMS Audit initiative involves deploying advanced technology and expanding the workforce of medical coders to clear a backlog of audits from 2018-2024 and audit all eligible MA contracts going…

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How Will Trump and Oz Handle Post Acute Medicare Advantage?

May 13, 2025

With the new administration, industry players are looking for signs of a trend in the management of Medicare Advantage (MA) plans, reflecting ongoing efforts to control costs, improve quality, and…

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Medicare Advantage Gets a Raise

April 4, 2025

The Trump administration’s final rule brought significant changes to Medicare Advantage (MA) plans for 2026, This rule increases capitation rates for MA plans by 5.1%, which is a substantial boost…

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CMS Releases Proposed 2026 Payment Policy Updates for Medicare Advantage and Part D Programs

January 10, 2025

Today, the Centers for Medicare & Medicaid Services (CMS) released the Calendar Year (CY) 2026 Advance Notice for the Medicare Advantage (MA) and the Medicare Part D Prescription Drug Programs…

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HHS-OIG’s Efforts Result in $7.13 Billion in Expected Recoveries and Receivables

December 4, 2024

America’s taxpayers could see recoupment of billions of dollars in misspent Medicare, Medicaid, and other health and human services funds as a result of work by the Department of Health…

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Medicare and Medicaid Programs; Contract Year 2026 Policy and Technical Changes to the Medicare Advantage Program

November 26, 2024

On November 26, 2024, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that would revise the Medicare Advantage (MA) Program, Medicare Prescription Drug Benefit Program (Part…

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Refusal of Recovery: How Medicare Advantage Insurers Have Denied Patients Access to Post-Acute Care

October 24, 2024

US Senate

The Senate Homeland Security and Governmental Affairs Committee’s majority staff report on Medicare Advantage highlights three key takeaways regarding overpayments and manipulative practices: Medicare Advantage plans are significantly overpaid: The…

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Assessing Medicaid Payment Rates and Costs of Caring for the Medicaid Population Residing in Nursing Homes: Final Report

October 11, 2024

HHS ASPE

The purpose of this research was to understand the relationship between state Medicaid payment rates to nursing homes and those facilities’ costs of providing care to Medicaid residents. Using 2019…

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Medicare Advantage: Questionable Use of Health Risk Assessments Continues To Drive Up Payments to Plans by Billions

October 1, 2024

Medicare Advantage (MA) companies receive higher risk-adjusted payments from the Centers for Medicare & Medicaid Services (CMS) for enrollees who are sicker, which helps to ensure that plans receive sufficient…

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Office of Inspector General: Managed Care Featured Topic

August 27, 2024

GAINING CLARITY: This compilation of OIG resources focused on managed care provides a centralized hub for understanding the oversight and compliance landscape related to Medicare Advantage plans, which play an…

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CMS Advancing Interoperability and Improving Prior Authorization Processes Final Rule (CMS-0057-F)

January 16, 2024

In early 2024, CMS published a new rule called “CMS Interoperability and Patient Access final rule (85 FR 25510)” calling on payers to comply with API policies that will improve…

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CMS’ Medicare Benefit Policy Manual

October 5, 2023

The Medicare Benefit Policy Manual is published online by the U.S. Centers for Medicare & Medicaid Services, or CMS. Its used by health care providers, contractors, Medicare Advantage companies and…

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High Rates of Prior Authorization Denials by Some Plans and Limited State Oversight Raise Concerns About Access to Care in Medicaid Managed Care

July 30, 2023

Three factors raise concerns that some people enrolled in Medicaid managed care may not be receiving all medically necessary health care services intended to be covered: (1) the high number…

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Some Medicare Advantage Organization Denials of Prior Authorization Requests Raise Concerns About Beneficiary Access to Medically Necessary Care

April 27, 2022

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Find More Medicare Advantage Resources

CMS’ Medicare Benefit Policy Manual

October 5, 2023

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Congress Focuses on Reforming Medicare Advantage Prior Authorization

May 23, 2025

US Senate

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CMS Rolls Out Aggressive Strategy to Enhance and Accelerate Medicare Advantage Audits

May 21, 2025

The CMS Audit initiative involves deploying advanced technology and expanding the workforce of medical coders to clear a backlog of audits from 2018-2024 and audit all eligible MA contracts going…

Read this article

How Will Trump and Oz Handle Post Acute Medicare Advantage?

May 13, 2025

With the new administration, industry players are looking for signs of a trend in the management of Medicare Advantage (MA) plans, reflecting ongoing efforts to control costs, improve quality, and…

Read this article

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Congress Focuses on Reforming Medicare Advantage Prior Authorization

CMS Rolls Out Aggressive Strategy to Enhance and Accelerate Medicare Advantage Audits

How Will Trump and Oz Handle Post Acute Medicare Advantage?

Medicare Advantage Gets a Raise

CMS Releases Proposed 2026 Payment Policy Updates for Medicare Advantage and Part D Programs

HHS-OIG’s Efforts Result in $7.13 Billion in Expected Recoveries and Receivables

Medicare and Medicaid Programs; Contract Year 2026 Policy and Technical Changes to the Medicare Advantage Program

Refusal of Recovery: How Medicare Advantage Insurers Have Denied Patients Access to Post-Acute Care

Assessing Medicaid Payment Rates and Costs of Caring for the Medicaid Population Residing in Nursing Homes: Final Report

Medicare Advantage: Questionable Use of Health Risk Assessments Continues To Drive Up Payments to Plans by Billions

Office of Inspector General: Managed Care Featured Topic

CMS Advancing Interoperability and Improving Prior Authorization Processes Final Rule (CMS-0057-F)

CMS’ Medicare Benefit Policy Manual

High Rates of Prior Authorization Denials by Some Plans and Limited State Oversight Raise Concerns About Access to Care in Medicaid Managed Care

Some Medicare Advantage Organization Denials of Prior Authorization Requests Raise Concerns About Beneficiary Access to Medically Necessary Care

Find More Medicare Advantage Resources

CMS’ Medicare Benefit Policy Manual

‘Not Accountable to Anyone’: As Insurers Issue Denials, Some Patients Run Out of Options

Elevance loses lawsuit over Medicare Advantage quality ratings

Humana must face class action suit over use of AI in denying post-acute care

Long-Term Services and Supports in Supplemental Benefits in Medicare Advantage Plans

Expanding PACE could further reduce taxpayer burden, improve care, report finds

The great Medicare Advantage contraction appears set to continue

Medicare Advantage in 2025: Enrollment Update and Key Trends

Medicare Advantage in 2025: Premiums, Out-of-Pocket Limits, Supplemental Benefits, and Prior Authorization

Most Medicare Advantage Markets are Dominated by One or Two Insurers

Enrollment in Dual-Eligible Special Needs Plans and Disenrollment Rates

Medicare Advantage Linked to Delays in Nursing Home Care, Longer Hospital Stays

CarDon CEO Zach Cattell: Managed Medicaid is ‘Biggest Wrench’ Pushing System Overhaul

Health insurers promise to reduce barriers to care under pressure from Trump administration

Medicare and the Health Care Delivery System

Medicare Advantage Denies 17 Percent Of Initial Claims; Most Denials Are Reversed, But Provider Payouts Dip 7 Percent

Congress Focuses on Reforming Medicare Advantage Prior Authorization

CMS Rolls Out Aggressive Strategy to Enhance and Accelerate Medicare Advantage Audits

Revealed: UnitedHealth secretly paid nursing homes to reduce hospital transfers

How Will Trump and Oz Handle Post Acute Medicare Advantage?

UnitedHealth stock tumbles as CEO resigns, 2025 outlook pulled