The insights into plan offerings, including premiums, supplemental benefits, and, most importantly, prior authorization policies, directly impact resident access, care coordination, and ultimately, facility reimbursement. By understanding these trends, particularly the growing use of prior authorization for skilled nursing care, facilities can proactively adapt admission processes, strengthen communication with MA plans, and advocate for transparent utilization review procedures.
In 2024, three quarters (75%) of enrollees in individual Medicare Advantage plans with prescription drug coverage pay no premium other than the Medicare Part B premium, which is a big selling point for beneficiaries, particularly those living on modest incomes and savings.
Most Medicare Advantage enrollees are in plans that offer supplemental benefits not covered by traditional Medicare, such as vision, hearing and dental. From 2023 to 2024, Medicare Advantage enrollees overall did not experience a significant loss in benefits despite concerns that changes in Medicare Advantage payment would lead to a drastic reduction in benefits or increase in premiums, though there were small declines in the share of enrollees in plans with access to some benefits from 2023 to 2024.
Nearly all Medicare Advantage enrollees (99%) are in plans that require prior authorization for some services, which is generally not used in traditional Medicare. Prior authorization is most often required for relatively expensive services, such as skilled nursing facility stays (99%), Part B drugs (98%), inpatient hospital stays (acute: 98%; psychiatric: 93%) and outpatient psychiatric services (82%) and is rarely required for preventive services (6%).
Freed, M., Biniek, J. F., Damico, A., & Neuman, T. (2024, August 8). Medicare advantage in 2024: premiums, Out-of-Pocket limits, supplemental benefits, and prior authorization | KFF. KFF. https://www.kff.org/medicare/issue-brief/medicare-advantage-in-2024-premiums-out-of-pocket-limits-supplemental-benefits-and-prior-authorization/
Improve Medicare Advantage reimbursements with payer contract management that puts payer rules in the hands of clinicians & billers.
