American Journal Of Managed Care Archives

MA Winter Roundup for SNFs: small gains and continued pressure

March 28, 2026

Our Take: Skilled nursing operators are seeing gains from proactive Medicare Advantage contract renegotiation; CMS is expands oversight of MA prior authorization and mandates the elimination of fax workflows by…

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Payer Roundup – March 2026

March 28, 2026

Our Take: KFF data confirms MA remains the highest-margin insurance segment, and regional plans are capturing enrollment gains as national insurers retreat. Federal enforcement of Medicare Advantage risk-adjustment fraud is…

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Contract Year 2027 Medicare Advantage and Part D Proposed Rule

March 14, 2026

Our Take: CMS’s CY2027 Medicare Advantage proposed rule streamlines Star Ratings and raises a red flag about dual-eligible enrollment in I-SNPs. The rule proposes that these nursing-home-focused plans may need…

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March 2026 Report to the Congress: Medicare Payment Policy

March 12, 2026

Our Take: MedPAC’s March 2026 report estimates Medicare is overspending by 14% on MA enrollees compared to FFS. This estimated $76 billion in higher costs is driven by favorable selection…

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MA recipients, dual eligibles less likely to be discharged to highly rated post acute rehab

February 24, 2026

Our Take: A JAMA study of more than 44,000 stroke patients finds that MA and dual-eligible beneficiaries are significantly less likely to be discharged to highly rated SNFs than traditional…

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Study Finds Significant Medicare Advantage Disenrollment as Market Adjustments Continue

February 18, 2026

Our Take: A JAMA research letter finds that forced MA disenrollments jumped from under 1% historically to an estimated 10% in 2026, affecting approximately 2.9 million enrollees. Enrollees are losing…

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Medicare Advantage Enrollment Grew by About 1 Million People, Mainly Due to Special Needs Plans

February 15, 2026

Our Take: Medicare Advantage reached 35 million enrollees in 2026, but overall growth slowed to just 3%, with special needs plans accounting for 83% of all new enrollment as the…

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Study of Discharge Appeals in a Skilled Nursing Facility

February 1, 2026

JAMDA

Our Take: About 1 in 10 post-acute SNF patients filed a discharge appeal at a single California facility, with 77% ultimately losing. The patients who lost faced a 27.8% 30-day…

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MA Denial Proof Mounts as CMS Moves Toward Mandatory Reporting

January 30, 2026

Our Take: Provider surveys and research document the scale of the Medicare Advantage denial burden in skilled nursing. CMS is advancing mandatory denial reporting and prior authorization pilots, while legislative…

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Medicare Advantage Insurers Made Nearly 53 Million Prior Authorization Determinations in 2024

January 28, 2026

Our Take: Medicare Advantage insurers made 53 million prior authorization requests in 2024, a 6% year-over-year increase. 7.7% of requests were denied, even as insurers publicly pledged to reduce administrative…

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CMS Proposes Nearly Flat Medicare Advantage Payment Rates for 2027

January 26, 2026

Our Take: CMS has proposed a 0.09% net average payment increase for Medicare Advantage plans in 2027, far below the 4% to 6% payers expected. MA payments stay essentially flat…

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Senate Report Finds UnitedHealth Turned Medicare Advantage Risk Adjustment into a Profit Strategy

January 12, 2026

Our Take: A 105-page Senate Judiciary Committee report, based on 50,000 pages of UnitedHealth’s own internal documents, concludes that the nation’s largest MA insurer built an engine to inflate risk…

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Payer Roundup – December 2025

December 31, 2025

Our Take: The December roundup documents an accelerating Medicare Advantage contraction with UnitedHealth projecting a 1 million-member enrollment drop in 2026. More than 40 health systems have severed MA contracts…

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Updates to Price Transparency Rules Pushed Out

December 19, 2025

Our Take: CMS has proposed significant updates to the Transparency in Coverage rules to restructure how hospitals and health plans publish machine-readable price files. These updates cut redundant data and…

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Insurers not fully complying with price transparency rules

December 9, 2025

Our Take: A peer-reviewed analysis of 2025 Transparency in Coverage files from Aetna, Cigna, and UnitedHealthcare finds significant gaps in completeness, particularly for hospital inpatient data. No insurer has been…

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Insurer use of algorithms cuts SNF length of stay

December 1, 2025

Our Take: A peer-reviewed study confirms that an MA insurer’s adoption of NaviHealth produced an immediate 13% decline in SNF length of stay, with stays over 30 days falling by…

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A Digest of How SNF Operators Are Navigating Medicare Advantage Complexity

November 30, 2025

Our Take: Growing financial and administrative pressures on skilled nursing facilities from Medicare Advantage is triggering broader industry education and sharing of best practices. Operators are managing MA with new…

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Prior Authorization Reform Heats Up

November 24, 2025

Our Take: At least 18 states enacted prior authorization reforms in 2025, outpacing federal regulators by requiring faster approval timelines, demanding evidence-based clinical review, and limiting AI-driven denials. These reforms…

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Chart Reviews Increase Payments to Medicare Advantage Insurers for 1 in 6 Enrollees

November 20, 2025

Our Take: Insurer-initiated chart reviews added diagnoses for 1 in 6 Medicare Advantage enrollees and generated an estimated $24 billion in additional federal payments to payer in 2023. Removals of…

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Complaints About Medicare Advantage Network Gaps Are Common. Federal Enforcement Is Rare

November 20, 2025

KFF

Our Take: CMS sent network adequacy violation letters to only five Medicare Advantage insurers over a six-year period and has never imposed civil monetary penalties, despite rampant complaints about provider…

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Push in Congress to Rein in Medicare Advantage

November 15, 2025

Our Take: Congress continued scrutiny of AI-driven denials and debating new prior authorization legislation. While these activities show continued momentum to reduce one of SNFs’ most persistent pain points –…

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Medicare Advantage Enrollment Among Long-Stay Nursing Home Residents Rose 183% From 2010 to 2023

November 14, 2025

Our Take: MA enrollment among long-stay nursing home residents tripled over 13 years, reaching 36.5% in 2023. But a recent sharp spike in MA disenrollment at the point of nursing…

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Provider-Led I-SNPs Reduce Nursing Home Hospitalizations but Raise Quality Questions

November 9, 2025

Our Take: Nursing homes that launch provider-led I-SNPs see hospitalizations fall and I-SNP enrollment surge. But the same financial incentives correlate with increased antipsychotic use, hypnotic drug use, and pressure…

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Medicare Advantage Reimbursement Structures Impact Home Health Delivery and Outcomes

November 6, 2025

American Journal of Managed Care

Our Take: When Medicare Advantage plans pay home health agencies on a per-visit basis and dictate visit counts and disciplines, patients face a 12% higher risk of inpatient transfer compared…

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Study Finds Medicare Advantage Beneficiaries Use Fewer Post-Acute Care Days With Equal or Better Outcomes

October 29, 2025

JAMA

Our Take: A study published on JAMA found that Medicare Advantage beneficiaries used 6.3 fewer SNF days and 3.6 fewer home health days than comparable traditional Medicare patients – and…

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Payer Roundup – September 2025

September 30, 2025

Our Take: The September digest raises the strong likelihood of a contraction in Medicare Advantage enrollment, with CMS projecting a decline of 900,000 enrollees in 2026. Yet HCSC is expanding…

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Are Hospital Stays Longer in Medicare Advantage?

September 8, 2025

Our Take: From 2017 to 2023, Medicare Advantage patients experienced disproportionately longer hospital stays than traditional Medicare patients. For patients headed to skilled nursing facilities, they were 3.1 percent more…

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Caregiving Among Dually Enrolled Older Adults

August 21, 2025

Our Take: A study in JAMA Network Open finds that despite MLTSS program coverage nearly doubling among community-dwelling dual enrollees between 2012 and 2022, unpaid family caregivers still account for…

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

August 11, 2025

Our Take: Six years after gaining the ability to offer LTSS supplemental benefits, Medicare Advantage plans have barely expanded availability. Only 12% of plans offered any LTSS benefit in 2025,…

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Health Care’s Colossus

August 11, 2025

STAT

Our Take: STAT’s eight-part “Health Care’s Colossus” series documents how UnitedHealth Group built a vertically integrated machine, leveraging physicians, algorithms, and self-funded research. The UHG machine can systematically extract Medicare…

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

August 7, 2025

Our Take: A new Pacific Research Institute analysis finds PACE saves taxpayers more than $2.8 billion annually – averaging $33,600 per participant per year – by keeping frail older adults…

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Medicare Advantage in 2025: Enrollment Update and Key Trends

July 28, 2025

Our Take: More than half of eligible Medicare beneficiaries are now enrolled in Medicare Advantage. Enrollment growth slowed to 4% in 2025, but SNP enrollment – especially C-SNPs – surged…

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

July 28, 2025

KFF

Our Take: KFF’s 2025 analysis finds that three quarters of Medicare Advantage enrollees pay no premium beyond Part B, while 99% are in plans that require prior authorization for skilled…

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Most Medicare Advantage Markets are Dominated by One or Two Insurers

July 14, 2025

KFF

Our Take: Despite doubling the number of available MA plans since 2018, virtually every U.S. county in 2024 remained highly or very highly concentrated, with one or two insurers controlling…

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Enrollment in Dual-Eligible Special Needs Plans and Disenrollment Rates

July 3, 2025

Our Take: Dual-eligible beneficiaries in fully integrated D-SNPs disenroll at just 8.1% annually – versus 28.2% in standard MA plans – demonstrating that deeper Medicare-Medicaid integration produces substantially stronger member…

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Payer Roundup – June 2025

June 30, 2025

Our Take: The June digest reports on a Medicare Advantage market under regulatory and legal pressure. UnitedHealth’s CEO resigned amid a criminal fraud investigation and a Guardian exposé revealing secret…

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June 2025 Report to the Congress: Medicare and the Health Care Delivery System

June 12, 2025

Our Take: MedPAC’s June 2025 congressional report identifies “design flaws” in Medicare Advantage programs serving nursing home residents and calls on Congress to enact meaningful MA reform. The report warns…

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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

Our Take: A study covering 30 percent of the MA market found that plans denied 17 percent of initial claims. Even after winning 57 percent of those denials on appeal,…

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Congress Focuses on Reforming Medicare Advantage Prior Authorization

May 23, 2025

US Congress

Our Take: Congress has introduced multiple bills since mid-2024 targeting Medicare Advantage prior authorization reform. Reform efforts have broad support from providers, payers, and lawmakers on both sides of the…

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CMS Launches Aggressive Overhaul of Medicare Advantage RADV Audit Program

May 21, 2025

Our Take: In May 2025, CMS announced a sweeping expansion of its Medicare Advantage Risk Adjustment Data Validation audit program. Annual audits will increase from roughly 60 plans to all…

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