Regulations & Policy

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Regulations & Policy

Learn how to address managed care's impact on post acute with details on regulations & policy, analysis & research and recent MA news

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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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…

Read this article

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…

Read this article

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

November 26, 2024

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Gain clarity on the Medicare Advantage payer rates and contract terms bogging down your team and affecting reimbursements.

Get a Sneak Peak!

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

With Medicare Advantage at a crossroads, will regulators keep plans’ unpopular deny-and-delay tactics in check?

Reduce Insurance Claim Denials

UnitedHealth AI Denials Lawsuit: Medicare Advantage Coverage Disputes

Mid-stream shift: Trump team to weigh unfinished Medicare Advantage coverage rules, program’s future

Best Practices for Medicare Advantage Case Management and Appeals

Negotiating to Win at Managed Care Contract Negotiations

A Guide to Medicare Advantage and Managed Care Contracting for Post Acute Providers

Medicare Advantage Insurers Made Nearly 50 Million Prior Authorization Determinations in 2023

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

Do Medicare Beneficiaries Under Accountable Care or Medicare Advantage Use Lower Quality Nursing Homes?

Medicare Advantage Fraud: Insurer to Pay $100M in Settlement

Expanding Medicare Advantage co-pays may leave nursing homes without cash they’ve earned

Medicare Spending was 27% More for People who Disenrolled from Medicare Advantage than for Similar People in Traditional Medicare

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

Medicare Advantage Proves To Be the ‘Most Profound’ Disruptor for Nursing Homes, Reshaping Payer Dynamics

Medicare Advantage 2025 Spotlight: A First Look at Plan Offerings

How to Survive Medicare Advantage in Home Health

What the Outcome of the Election Could Mean for Medicaid

The Sickest Patients Are Fleeing Private Medicare Plans—Costing Taxpayers Billions