Health Care Plan Accountability Update - March 25, 2025

TOP NEWS

AHA report examines how growth of MA heightens challenges for rural hospitals

A new AHA report highlights how certain practices by Medicare Advantage plans are increasing rural hospitals' vulnerabilities and threatening access to care in rural communities.   

In the report, the AHA found that rural hospitals are receiving only 90.6% of Traditional Medicare rates on a cost basis from MA plans. The report also found that insurers’ requirements interfere with clinicians’ ability to provide timely and effective care. For example, 81% of rural clinicians report declines due to insurer requirements. Rural MA patients face longer hospital stays as well, spending 9.6% more time in the hospital before transitioning to post-acute care compared to similar Traditional Medicare patients. Administrative burdens have also grown, with nearly 4 in 5 rural clinicians reporting an increase in administrative tasks over the past five years, and 86% saying these demands have negatively impacted patient outcomes.

“With MA plans accounting for more than half of total Medicare enrollment and growing, it’s more important than ever that the program works for patients and the providers who care for them,” said AHA President and CEO Rick Pollack. “It is critical for policymakers to address the harmful impact of Medicare Advantage’s low reimbursements and excessive administrative burdens to help ensure rural hospitals can continue to provide care to their patients and communities." 

AHA releases 2025 Advocacy and Rural Advocacy agendas

The AHA released its 2025 Advocacy Agenda  detailing the association's key priorities for Congress, the Administration, regulatory agencies and courts. AHA also released its 2025 Rural Advocacy Agenda which includes the difficulties rural hospitals face due to challenges imposed by commercial and Medicare Advantage plans. 

CMS finalizes notice of benefit and payment parameters for 2026  

The Centers for Medicare & Medicaid Services released its standards for the health insurance marketplaces for 2026, including those for the issuers and brokers who assist marketplace enrollees. The final rule enhances CMS' authority to address and curtail misconduct by agents and brokers, such as fraudulent changes to an enrollee's health care coverage. The final rule went into effect Jan. 15.  

CMS says record 24.2 million enrolled in Marketplace coverage for 2025  

The Centers for Medicare & Medicaid Services announced a record 24.2 million consumers selected health coverage through the Health Insurance Marketplace for the 2025 enrollment period that ended Jan. 15. The total was more than double the number of enrollees from 2021, CMS said. Of this year's total, 3.9 million consumers signed up for the first time. 

AHA supports policy, technical changes to Medicare Advantage, Part D for 2026 

The AHA voiced support for the Centers for Medicare & Medicaid Services' proposed rule on policy and technical changes to Medicare Advantage and Part D for contract year 2026. The proposal includes strengthened oversight of Medicare Advantage Organizations and provided additional protections to ensure MA beneficiary access to basic benefits. It also includes provisions promoting more timely access to care, strengthening behavioral health provider networks, and reducing the administrative burden of plan requirements on health care providers.   

MEDICARE ADVANTAGE NEWS 

KFF: MA insurers made nearly 50 million prior authorization determinations in 2023 

An analysis by KFF released Jan. 28 found that Medicare Advantage insurers made nearly 50 million prior authorization determinations in 2023. The finding reflects continued year-over-year increases from 2022 (42 million) and 2021 (37 million) as more people have enrolled in MA. KFF also found that in 2023 there was an average of nearly two prior authorization determinations per MA enrollee.   

The analysis found that insurers fully or partially denied 3.2 million prior authorization requests (6.4%) in 2023, a smaller share than 2022 (7.4%). In 2023, 11.7% of denied prior authorization requests were appealed in MA and of those cases, 81.7% were partially or fully overturned 

TELL US YOUR STORY

We want to hear about your experience with commercial health plans and how inappropriate use of prior authorization, payment delays and other harmful policies are affecting your patients. We welcome submissions in writing or by video or image upload. We will not use any information publicly without your permission.

Log in to our AHA.org to access the Health Plan Accountability page and scroll to the bottom to submit your story or experience. You may also upload documents, videos or other supporting material.