For post-acute providers, this data confirms that MA’s utilization controls are firmly in place and prior auth barriers at the SNF level show no signs of retreating. Skilled nursing facilities should expect continued prior authorization scrutiny from MA plans, with 99% of enrollees in plans requiring prior auth for SNF stays — a figure that persists even as CMS has increased regulatory pressure on the practice. The durability of MA’s zero-premium model also signals continued enrollment growth into MA, reinforcing the urgency of strong contracting and utilization management strategies for post-acute providers.
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%).
— KFF, August 8, 2024
Freed, Meredith, et al. “Medicare Advantage in 2024: Premiums, Out-of-Pocket Limits, Supplemental Benefits, and Prior Authorization.” KFF, 8 Aug. 2024. https://www.kff.org/medicare/medicare-advantage-in-2024-premiums-out-of-pocket-limits-supplemental-benefits-and-prior-authorization/.
✔ Comply with every payer's rules
✔ Equip your team with the Playbook
✔ Monitor rates and payer trends
