Gaining Clarity Guides

CMS’ Medicare Benefit Policy Manual

October 5, 2023

CMS

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

August 21, 2025

KFF

…Health insurers issue millions of denials every year. And like the Tennants, many patients find themselves stuck in a convoluted appeals process marked by long wait times, frustrating customer service…

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Elevance loses lawsuit over Medicare Advantage quality ratings

August 19, 2025

STAT

A federal judge in Texas struck down Elevance Health’s lawsuit that argued the government unfairly lowered its Medicare Advantage quality ratings — a decision that could cost Elevance $375 million…

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

August 18, 2025

McKnights

Humana must face a class action lawsuit alleging that its use of artificial intelligence to deny post-acute care to Medicaid Advantage beneficiaries became fraud when those automated decisions replaced the…

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

August 11, 2025

JAMA

To what extent have Medicare Advantage (MA) plans provided long-term services and supports (LTSS) supplemental benefits over time? In this cohort study of 4,521 MA plans in 2019 and 6,614…

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

August 7, 2025

McKnights

The Program of All-Inclusive Care for the Elderly saves taxpayers more than $2.8 billion annually, according to a new issue brief from the Center for Medical Economics and Innovation at…

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The great Medicare Advantage contraction appears set to continue

August 6, 2025

Healthcare Dive

Shakespeare famously wrote in The Tempest, “What’s past is prologue,” to express how events of the past set the stage for developments in the present. That sentiment was clear for…

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Medicare Advantage in 2025: Enrollment Update and Key Trends

July 28, 2025

KFF

More than half (54%) of eligible Medicare beneficiaries are enrolled in Medicare Advantage in 2025. While a growing share of Medicare beneficiaries are enrolled in a Medicare Advantage plan, the…

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

July 28, 2025

KFF

In 2025, more than three quarters (76%) of enrollees in individual Medicare Advantage plans with prescription drug coverage pay no premium other than the Medicare Part B premium, which is…

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Most Medicare Advantage Markets are Dominated by One or Two Insurers

July 14, 2025

KFF

Enrollment in Medicare Advantage, the private plan alternative to traditional Medicare, has increased steadily since 2010. The average beneficiary has access to 34 Medicare Advantage plans with prescription drug coverage…

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Enrollment in Dual-Eligible Special Needs Plans and Disenrollment Rates

July 3, 2025

JAMA

Is enrollment in Medicare Advantage plans with greater degrees of integration associated with lower plan disenrollment rates? In this cross-sectional study of 2.7 million dually eligible Medicare beneficiaries, dually eligible…

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

June 25, 2025

Skilled Nursing News

Amid increasing evidence that prior authorization and denials in Medicare Advantage (MA) may delay access to nursing homes, a new study shows that MA patients often experience longer hospital stays…

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

June 24, 2025

Skilled Nursing News

As Zach Cattell, the newly appointed president and CEO of CarDon & Associates, celebrates wins, he is mindful of several challenges stemming from both federal and state policies, with the…

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

June 23, 2025

STAT

Last week’s pledge from more than 40 health insurers to cut down on prior authorizations came after some behind-the-scenes convincing from the Trump administration. The administration pushed insurers to sign…

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Medicare and the Health Care Delivery System

June 12, 2025

MedPAC

MedPAC also highlighted institutional special needs plans (I-SNPs) for nursing home residents, highlighting their potential for improved care coordination despite limitations in data and access. The report also touches on…

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

June 1, 2025

Health Affairs

This article quantifies the prevalence of claim denials in Medicare Advantage (MA), along with their direct impact on provider revenue. Employing medical claims data from multiple MA plans, covering 30…

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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

CMS

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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Revealed: UnitedHealth secretly paid nursing homes to reduce hospital transfers

May 21, 2025

Wall Street Journal

A Guardian investigation finds insurer quietly paid facilities that helped it gain Medicare enrollees and reduce hospitalizations. Whistleblowers allege harm to residents UnitedHealth Group, the nation’s largest healthcare conglomerate, has…

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How Will Trump and Oz Handle Post Acute Medicare Advantage?

May 13, 2025

CMS

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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UnitedHealth stock tumbles as CEO resigns, 2025 outlook pulled

May 13, 2025

STAT

UnitedHealth Group CEO Andrew Witty abruptly stepped down from the health insurance and care conglomerate on Tuesday, citing personal reasons, capping the end of a tumultuous four-year tenure that included…

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Best Practices for Medicare Advantage Case Management and Appeals

Negotiating to Win at Managed Care Contract Negotiations

Using Price Transparency Data to Gain a Competitive Edge

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

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