Medicare Secondary Payer rules determine when Medicare becomes the second payer for beneficiaries with other insurance coverage. For U.S. healthcare executives, MSP compliance represents a complex operational challenge with direct financial implications, heightened enforcement risk, and evolving regulatory requirements that demand systematic attention.

What is Medicare Secondary Payer?

Medicare Secondary Payer refers to situations where the Medicare program does not hold primary payment responsibility. When another entity—a group health plan, liability insurer, no-fault insurer, or workers’ compensation program has the obligation to pay first, Medicare becomes the secondary payer.

Enacted in 1980, MSP legislation shifted costs from Medicare to appropriate private payment sources. Before MSP, Medicare paid first for nearly all claims except those covered by Workers’ Compensation, Federal Black Lung benefits, and Veterans Administration benefits. Today, MSP provisions protect the Medicare Trust Fund by ensuring Medicare does not pay for services when other coverage is primarily responsible.

The distinction is operational, not theoretical. Providers must identify primary payers, bill them first, and only submit claims to Medicare after receiving the primary payer’s adjudication. Federal law takes precedence over state laws and private contracts. Even when state law or an insurance policy suggests Medicare should pay first, MSP provisions apply.

Why Medicare Secondary Payer Matters Now

1. Financial Impact on Medicare Trust Fund

MSP savings are substantial. According to the Department of Health and Human Services, MSP laws and regulations reduced Medicare spending by approximately $9.7 billion in fiscal year 2021. These provisions are not peripheral—they are vital to Medicare’s fiscal integrity.

The 2024 Medicare Board of Trustees’ report projects that total Part A spending will exceed incoming revenues by 2030. By 2036, insufficient funds will exist to pay full benefits. MSP recovery and coordination efforts directly address this solvency challenge.

2. Increased CMS Enforcement in 2025

CMS formalized civil money penalty (CMP) authority in October 2023. Penalties became enforceable in October 2024. CMS now randomly audits 250 submissions each calendar quarter, imposing penalties of $1,000 per day for untimely reporting.

This represents a fundamental shift. What was once primarily a compliance obligation with limited enforcement has become an area where CMS actively monitors, audits, and penalizes non-compliance. Responsible Reporting Entities (RREs)—including insurance carriers, self-insureds, and third-party administrators—face real financial exposure for reporting failures.

3. New Reporting Requirements Taking Effect

April 4, 2025 marked a watershed moment for workers’ compensation settlements. CMS now mandates Section 111 reporting of Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA) data for all settlements involving Medicare beneficiaries, including those with zero-dollar allocations and settlements below the $25,000 CMS review threshold.

This gives CMS unprecedented visibility into settlement practices. The agency now knows whether future medical allocations were included in low-dollar settlements and when no WCMSA was established. This data enables enhanced coordination of benefits and identifies potential compliance gaps.

How Medicare Secondary Payer Works

Medicare remains the primary payer for beneficiaries without other health insurance coverage. However, specific situations trigger secondary payer status:

Medicare pays primary when:

• The beneficiary has no other insurance
• The beneficiary has only Medicare Supplement (Medigap) insurance
• The group health plan covering the beneficiary is from a small employer (fewer than 20 employees for working aged; fewer than 100 employees for disabled beneficiaries)
• The 30-month coordination period for ESRD has ended and other coverage remains through employment

Medicare pays secondary when:

• A beneficiary age 65 or older has group health plan coverage through current employment (their own or a spouse’s) with an employer of 20 or more employees
• A disabled beneficiary under 65 has group health plan coverage through current employment (their own or a family member’s) with an employer of 100 or more employees
• A beneficiary has ESRD and group health plan coverage during the first 30 months of Medicare eligibility
• Payment has been made or can reasonably be expected from liability insurance, no-fault insurance, or workers’ compensation

The Five Main MSP Categories

1. Working Aged: Beneficiaries age 65 or older covered by a group health plan through current employment where the employer has 20 or more employees.

2. Disability: Beneficiaries entitled to Medicare based on disability who are covered under a group health plan through current employment where the employer has 100 or more employees.

3. End-Stage Renal Disease (ESRD): Beneficiaries with ESRD who have group health plan coverage during the 30-month coordination period following Medicare eligibility.

4. Liability Insurance (including self-insurance): Coverage that may be responsible for payment when a beneficiary’s medical condition results from an accident or alleged negligence of another party.

5. No-Fault Insurance and Workers’ Compensation: Coverage for medical expenses resulting from automobile accidents (no-fault) or work-related injuries or illnesses (workers’ compensation).

The Role of the Benefits Coordination & Recovery Center (BCRC)

The BCRC administers coordination of benefits for Medicare by maintaining the Common Working File (CWF), a CMS database that stores MSP data and investigation information. The BCRC collects data from multiple sources including IRS/SSA/CMS data matches, voluntary data sharing agreements with large employers, and mandatory Section 111 reporting from insurers.

When the BCRC identifies that another payer should be primary to Medicare, it posts an MSP occurrence to Medicare’s records. This information flows to Medicare Administrative Contractors (MACs) who use it to process claims correctly.

The BCRC also manages conditional payment recovery for non-group health plan situations. When Medicare pays conditionally for services that should have been covered by liability, no-fault, or workers’ compensation insurance, the BCRC seeks reimbursement after settlement, judgment, or award.

MSP Impact on Healthcare Operations

1. Cost Implications for Providers

MSP compliance affects the bottom line in several ways. First, claims submitted incorrectly as primary when Medicare should be secondary will be denied, creating rework and delaying payment. Clean claim rates drop when MSP information is missing or inaccurate.

Second, Medicare’s secondary payment amount is calculated based on the primary payer’s allowed amount and payment. If a provider has a favorable contract with the primary payer, Medicare’s secondary payment may be minimal. Understanding this calculation is essential for accurate revenue forecasting.

Third, conditional payments create recovery obligations. If Medicare pays conditionally and later determines another payer was responsible, Medicare seeks reimbursement. Providers who received the conditional payment may face recovery demands if they also collected from the primary payer.

2. Claims Processing and Revenue Cycle Effects

MSP adds complexity to every stage of the revenue cycle. Registration staff must collect comprehensive insurance information. Billing staff must verify which payer is primary before submitting claims. Claims must include specific MSP-related codes, condition codes, occurrence codes, and value codes to process correctly.

When Medicare is secondary, claims cannot be submitted until the primary payer has adjudicated the claim. The Explanation of Benefits (EOB) from the primary payer must accompany the Medicare claim. This sequential billing extends days in accounts receivable.

Electronic claims require proper loop and segment population for MSP information. Paper claims require specific form completion. Common billing errors include claims that don’t balance (when adjustment amounts don’t equal the total charge), missing value codes for auto/no-fault/workers’ compensation situations, and incorrect payer sequencing.

3. Compliance Requirements and Documentation Burden

Providers must make good faith efforts to determine whether Medicare is the primary or secondary payer. This requires asking beneficiaries specific questions about their insurance coverage during intake, admission, and at regular intervals for recurring services.

Documentation requirements are extensive. Providers must:

• Ask MSP-related questions at each hospital admission and outpatient visit
• Verify MSP information every 90 days for recurring outpatient services
• Maintain records of insurance information collected
• Keep documentation showing they asked the required questions, even when the beneficiary states nothing has changed
• Retain records for at least three years after the service date

For workers’ compensation situations, providers must inquire whether the beneficiary is taking legal action and bill workers’ compensation first even when the claim is disputed, unless workers’ compensation will not pay promptly.

Common MSP Mistakes Healthcare Providers Make

1. Failing to Verify Insurance at Each Encounter

The most frequent MSP error is inadequate insurance verification. Many providers collect insurance information once and never update it. Employment status changes. Spouses retire. COBRA coverage ends. Each change potentially affects MSP status.

CMS requires verification at specific intervals:

• Each inpatient hospital admission
• Each hospital outpatient visit
• Every 90 days for recurring outpatient services

Providers often misunderstand “recurring services.” These are identical services and treatments received on an outpatient basis more than once within a billing cycle. For such services, MSP information must be no older than 90 days from the service date.

2. Incomplete or Incorrect Claim Coding

MSP claims require specific coding elements. Missing or incorrect codes trigger denials. Common coding errors include:

Missing payer codes: Payer codes identify insurance coverage type. Each coverage category requires a specific payer code driven by the value codes reported on the claim.

Incorrect value codes: Value code 44 (other than accident-related) indicates the amount the provider agreed to accept from the primary payer as payment in full. Medicare uses this amount in its secondary payment calculation. Omitting VC 44 when applicable or using it incorrectly affects payment.

Missing Claim Adjustment Reason Codes (CARC): These codes explain why the primary payer’s paid amount differs from the billed amount. CMS requires CARC codes for all adjustments made by the primary payer.

Claims that don’t balance: MSP claims reject when primary claim adjustment amounts in the CAS segment plus the amount paid by the primary in the AMT segment don’t equal the total charge.

3. Not Understanding Conditional Payment Recovery

Many providers believe that once Medicare pays a claim, the transaction is complete. This is not true for MSP situations involving liability, no-fault, or workers’ compensation.

When Medicare makes a conditional payment—paying for services another payer may be responsible for—Medicare retains recovery rights. The payment is “conditional” because it must be repaid when a beneficiary receives a settlement, judgment, award, or other payment.

Providers sometimes collect from both Medicare (conditional payment) and the primary payer. Medicare then seeks recovery of the conditional payment. Understanding this recovery process is essential to avoid duplicate payments and subsequent recovery demands.

4. Missing the 90-Day Verification Window for Recurring Services

The 90-day verification requirement for recurring outpatient services is widely misunderstood. Providers often verify insurance at the start of a treatment series and assume this suffices for months of ongoing care.

When audited, CMS expects documentation showing MSP information was verified within 90 days of each service date for recurring services. “Verified” means asking the questions, not just confirming that insurance information looks the same in the system.

Providers should implement systematic prompts in their registration systems to trigger re-verification at appropriate intervals. Documentation should explicitly note that MSP questions were asked and record the beneficiary’s responses or statement that nothing has changed.

Group Health Plans vs. Non-Group Health Plans: Understanding the Difference

1. GHP Rules for Working Aged and ESRD Patients

Group Health Plans operate under specific size thresholds. For working aged beneficiaries (65 or older), the employer must have 20 or more employees for the GHP to be primary. For disabled beneficiaries under 65, the employer must have 100 or more employees.

These thresholds apply per employer, not per plan. All common law employees count, including part-time employees, regardless of whether they’re enrolled in the GHP. Separate legal entities under common ownership may be aggregated when determining size.

ESRD presents unique rules. During the first 30 months of Medicare eligibility based on ESRD, group health plan coverage through current employment remains primary. After 30 months, Medicare becomes primary. This is called the “30-month coordination period.”

If the beneficiary has ESRD and also qualifies for Medicare based on age or disability, separate rules apply depending on which entitlement came first. Providers should consult CMS guidance for these dual entitlement scenarios.

2. NGHP Coverage: Liability, No-Fault, and Workers’ Compensation

Non-Group Health Plans include liability insurance (including self-insurance), no-fault insurance, and workers’ compensation. These coverages typically arise from unexpected incidents: car accidents, work-related injuries, or injuries caused by another party’s negligence.

When an NGHP situation exists, Medicare will not pay for injury-related care if payment has been made or can reasonably be expected from the NGHP. If the NGHP insurer will not pay promptly—or if responsibility is disputed—Medicare may make conditional payments to ensure the beneficiary has access to care.

Providers must bill the NGHP first. Only after receiving the NGHP’s denial or if the NGHP will not pay promptly may the provider submit a conditional payment request to Medicare. This requires specific documentation explaining why the primary payer did not pay.

MSP Conditional Payments and Recovery Process

A conditional payment is a payment Medicare makes for services another payer may be responsible for. Medicare makes conditional payments so beneficiaries do not have to use their own money to pay medical bills while determining liability or waiting for settlements.

The payment is “conditional” because it must be repaid to Medicare when a settlement, judgment, award, or other payment is made. Medicare’s recovery rights are established by federal statute (42 U.S.C. § 1395y(b)) and override state laws and private contracts.

Conditional payments most commonly occur in liability, no-fault, and workers’ compensation situations. When a beneficiary is injured in a car accident or at work, medical care begins immediately. Determining who will ultimately pay may take months or years while liability is investigated and claims are negotiated. Medicare pays conditionally to ensure the beneficiary receives necessary care.

A. How the Recovery Process Works

The conditional payment recovery process follows several stages:

1. Reporting the case: When a liability, no-fault, or workers’ compensation case exists, it must be reported to the BCRC. This can be done by the beneficiary, their attorney, the insurer, or a provider aware of the situation. Reporting triggers the BCRC’s investigation.

2. BCRC investigation: The BCRC collects information from multiple sources including claims processors, Section 111 mandatory insurer reporting, and workers’ compensation entities. The BCRC identifies any conditional payments Medicare made that relate to the injury or illness.

3. Conditional Payment Letter (CPL) or Conditional Payment Notice (CPN): The BCRC sends a letter listing the conditional payments Medicare made and their total amount. This letter provides 30 calendar days to respond.

4. Dispute process: If the beneficiary or their representative believes certain claims should not be included, they must submit documentation supporting that position. The BCRC reviews disputes and adjusts the conditional payment amount if it agrees the claims are unrelated. This review takes up to 45 days.

5. Final demand: Once disputes are resolved and a settlement occurs, the BCRC issues a final demand letter specifying the repayment amount. This amount must be paid from the settlement proceeds.

6. Payment: Payment can be made via pay.gov using ACH, debit card, or PayPal. Failure to repay Medicare’s conditional payments can result in the debt being referred to the Department of Treasury for collection.

B. Using the Medicare Secondary Payer Recovery Portal (MSPRP)

The MSPRP is a web-based tool that allows attorneys, insurers, beneficiaries, and recovery agents to manage MSP recovery cases online. The portal provides several capabilities:

• Viewing conditional payment amounts in real time
• Submitting proof of representation and consent to release documentation
• Initiating demand letters earlier than the default 30-day period
• Disputing individual claims included in the conditional payment amount
• Requesting access to unmasked claims data
• Making electronic payments
• Tracking correspondence and case status

Registration is required before accessing the MSPRP. Users must complete identity proofing and multi-factor authentication to request access to unmasked claims data.

The MSPRP significantly accelerates the resolution process. Before the portal, everything occurred via mail and fax with extensive delays. The portal allows real-time updates and substantially reduces resolution timelines.

C. Timeline and Appeal Rights

The recovery process has defined timelines. After receiving a conditional payment letter or notice, parties have 30 days to respond. If no response is received, the BCRC may issue a demand letter.

After a demand letter is issued, beneficiaries have appeal rights. The first level of appeal is a redetermination. Redetermination requests must be filed within 120 days of receiving the demand letter. The redetermination officer reviews the case and issues a decision.

If the redetermination is unfavorable, subsequent appeal levels include reconsideration by a Qualified Independent Contractor (QIC), Administrative Law Judge hearing, Medicare Appeals Council review, and judicial review in federal district court.

Waivers of recovery are available in limited circumstances. Beneficiaries may request a waiver if recovering the conditional payment would cause financial hardship or if they were not at fault in creating the overpayment situation. Waiver requests cannot be processed until after a recovery demand letter is issued.

Old Way vs. Modern Approach to MSP Compliance

Old Way:

• Passive insurance verification at admission only
• Manual paper-based claims submission with minimal MSP coding
• Reactive response to Medicare denials and recovery demands
• Limited understanding of conditional payment obligations
• Minimal technology support beyond basic claims systems
• Siloed compliance efforts without cross-functional coordination
• Treating MSP as a billing issue rather than an enterprise risk

Modern Approach:

• Systematic verification at every encounter with automated prompts
• Electronic claims with comprehensive MSP data elements and validation edits
• Proactive identification of MSP situations before claims submission
• Clear recovery process workflows with designated staff responsibilities
• Integrated technology platforms connecting eligibility, claims, and compliance functions
• Cross-functional compliance teams involving revenue cycle, compliance, legal, and clinical leadership
• Enterprise risk management framework treating MSP as a financial and regulatory exposure requiring board-level attention

The modern approach recognizes that MSP compliance cannot be relegated to billing staff. It requires organizational commitment, technology investment, and systematic processes spanning registration through final payment resolution.

Leading organizations implement real-time eligibility checking that queries CMS systems to identify MSP indicators before services are rendered. They use automated claim scrubbing that validates MSP coding requirements before submission. They establish dedicated conditional payment coordinators who manage recovery cases and interface with the BCRC.

Most importantly, they treat MSP compliance as a strategic priority rather than an operational nuisance. Executive dashboards track MSP-related denials, recovery demands, and compliance metrics. Compliance committees review MSP performance quarterly. Leadership allocates resources to technology and training that prevent errors upstream rather than fixing them downstream.

The Next 12-36 Months: What Healthcare Leaders Should Expect

1. Enhanced CMS Monitoring and Auditing

CMS’s enforcement posture will continue strengthening. The civil money penalty framework established in 2023-2024 represents the beginning of enhanced enforcement, not its conclusion.

Expect expanded audit activity. CMS currently audits 250 quarterly submissions (1,000 annually). This may increase as CMS gains confidence in its audit processes and as agency resources grow.

Expect data analytics to drive audit selection. CMS now has unprecedented data through Section 111 reporting, including WCMSA information. The agency will identify statistical outliers—RREs with unusual reporting patterns, late submissions, or zero-dollar MSAs in circumstances suggesting underfunding. These outliers will receive closer scrutiny.

Expect False Claims Act activity to increase. The Department of Justice has shown interest in MSP non-compliance as a potential False Claims Act theory. Failure to properly identify and bill primary payers before Medicare may constitute false claims. Qui tam relators (whistleblowers) are increasingly focusing on MSP-related issues.

Healthcare leaders should prepare for this enhanced environment by establishing robust compliance programs, conducting internal audits to identify gaps, and remediating issues proactively before they become enforcement targets.

2. Technology Solutions Gaining Traction

Technology vendors are developing increasingly sophisticated MSP compliance solutions. These tools integrate with core systems to provide:

Real-time eligibility verification: Automated queries to CMS Coordination of Benefits databases during registration, surfacing MSP indicators immediately so registration staff can collect proper insurance information.

Rules-based claim validation: Pre-submission validation that checks claims for required MSP data elements, verifies coding logic, and flags potential errors before claims leave the organization.

Predictive analytics: Machine learning models that identify high-risk claims likely to generate MSP-related denials based on historical patterns.

Workflow automation: Automated routing of MSP-related tasks to appropriate staff, deadline tracking for conditional payment responses, and systematic follow-up on pending issues.

Reporting and analytics: Dashboards providing visibility into MSP denial rates, recovery demand volumes, compliance metrics, and financial impact.

Organizations should evaluate these solutions based on integration capabilities with existing systems, vendor expertise in MSP compliance, implementation support, and total cost of ownership. The right technology can significantly reduce manual effort while improving accuracy and compliance.

3. Policy Evolution and Regulatory Clarity

CMS will likely continue refining MSP guidance. The WCMSA Reference Guide has undergone multiple revisions in 2025 alone. The Section 111 User Guide updates regularly. This pattern will persist as CMS responds to industry feedback and emerging compliance issues.

Legislative activity may occur. Congressional interest in Medicare solvency creates potential for MSP-related legislation. Possible areas include:

• Standardization of WCMSA thresholds and processes
• Expansion of mandatory reporting beyond current requirements
• Enhanced CMS audit authority and penalties
• Private right of action provisions allowing Medicare beneficiaries to sue for MSP violations

Healthcare leaders should monitor regulatory developments through industry associations, CMS updates, and legal counsel. Participating in comment periods when CMS proposes rule changes allows organizations to shape policy and prepare for implementation.

The trajectory is clear: MSP compliance requirements will become more detailed, enforcement will intensify, and technology will play an increasingly central role. Organizations that prepare now will manage this transition more effectively than those waiting for problems to emerge.

Practical Takeaways for U.S. Healthcare Leaders

1. Treat MSP as an enterprise risk, not a billing issue. MSP compliance requires executive attention, cross-functional coordination, and board-level oversight. Financial exposure from penalties, recovery demands, and denied claims can be substantial.

2. Implement systematic verification processes at every encounter. One-time insurance collection at admission is insufficient. Build verification prompts into registration workflows at each service date and every 90 days for recurring services. Document that questions were asked and record responses.

3. Invest in technology that prevents errors upstream. Real-time eligibility checking, automated claim validation, and workflow management tools reduce manual effort while improving accuracy. The ROI from reduced denials and faster payment typically justifies technology investments.

4. Establish clear accountability for conditional payment management. Designate specific staff responsible for monitoring conditional payment notifications, responding to BCRC inquiries, managing disputes, and coordinating with legal counsel when necessary. These responsibilities cannot be “additional duties as assigned” for already-overloaded billing staff.

5. Conduct regular internal audits of MSP compliance. Review claims data to identify MSP-related denials, analyze root causes, and implement corrective actions. Audit documentation of insurance verification to ensure processes are being followed. Identify training needs and address gaps proactively.

6. Develop relationships with specialized MSP counsel. Complex MSP situations—particularly involving conditional payments, WCMSAs, and Section 111 reporting—require specialized legal expertise. Establish relationships with attorneys experienced in MSP compliance before problems arise.

7. Monitor regulatory developments and participate in policy discussions. CMS guidance evolves continuously. Subscribe to CMS listservs, participate in industry associations, and allocate staff time to staying current with changes. When opportunities arise to comment on proposed rules, provide input based on operational experience.

Medicare Advantage has crossed a watershed moment: more than half of all eligible Medicare beneficiaries 54% as of 2025 now receive their coverage through private insurance plans rather than traditional Medicare. This represents 34.1 million people out of approximately 62.8 million Medicare beneficiaries with Parts A and B, and the Congressional Budget Office projects this will climb to 64% by 2034.

For healthcare executives, health system leaders, and policy-aware operators, this shift isn’t just a market trend; it’s a fundamental restructuring of how Medicare operates, how revenue flows through the system, and how care gets delivered. Understanding Medicare Advantage’s mechanics, financial implications, and operational realities has become essential to strategic planning in U.S. healthcare.

What Is Medicare Advantage?

Medicare Advantage (MA), also known as Medicare Part C, is an alternative to traditional fee-for-service Medicare. Instead of the federal government paying providers directly for each service rendered, Medicare pays private insurance companies a fixed monthly amount per enrollee. These MA organizations (MAOs) then assume responsibility for providing all Medicare-covered benefits and often add supplemental benefits not available in traditional Medicare.

Traditional Medicare operates as a single-payer, fee-for-service system. Beneficiaries can see any provider who accepts Medicare, pay standardized cost-sharing (20% coinsurance for Part B services, no out-of-pocket maximum), and receive coverage for Medicare-defined services only. Medicare Advantage, by contrast, operates through managed care structures typically HMOs, PPOs, or Private Fee-for-Service plans with provider networks, prior authorization requirements, and the ability to negotiate rates with providers.

How the Payment Model Works

Medicare pays MA plans through a risk-adjusted capitation model. CMS calculates a “benchmark” for each county based on traditional Medicare spending in that area, adjusted for factors including:

• County-level fee-for-service costs
• Quality bonus payments (Star Ratings)
• Demographic characteristics
• Risk scores reflecting enrollee health status

Plans submit bids indicating what they believe it will cost to provide Medicare-covered benefits. If a plan’s bid comes in below the benchmark, the plan receives a rebate—a percentage of the difference—which must be used to provide additional benefits, reduce premiums, or lower cost-sharing. In 2024, benchmarks averaged 108% of traditional Medicare spending before accounting for coding intensity or favorable selection. Bids averaged 82% of traditional Medicare spending. After rebates, payments reached approximately 100% of traditional Medicare spending—before adjusting for the two factors that drive overpayment concerns: coding intensity and favorable selection.

Why Medicare Advantage’s Growth Matters Now

Medicare Advantage enrollment grew by 1.3 million beneficiaries between 2024 and 2025, a 4% increase. While this growth rate has decelerated from the 7% increase seen the prior year, the absolute numbers remain substantial. The program is projected to cost taxpayers $507 billion in 2026.

UnitedHealth Group dominates the market with 29% of all MA enrollment in 2025, up from 18% in 2010. Combined with Humana at 17%, these two organizations control 46% of the entire Medicare Advantage market. Behind them, Elevance Health, CVS (Aetna), and Blue Cross Blue Shield plans round out the top tier, while market concentration continues to increase.

Special Needs Plans—designed for dual-eligible beneficiaries, those with chronic conditions, or those requiring institutional-level care—are driving disproportionate growth. SNPs captured 48% of the total enrollment increase between 2024 and 2025, despite representing only 21% of total MA enrollment. Within this segment, Dual-Eligible SNPs (D-SNPs) account for 83% of SNP enrollment, reflecting both the program’s appeal to vulnerable populations and plans’ strategic focus on high-margin segments.

Financial Implications for the Medicare Program

The Medicare Payment Advisory Commission estimates that Medicare Advantage plans will be overpaid by $76 billion in 2026 compared to what the government would spend if those same beneficiaries remained in traditional Medicare. The Committee for a Responsible Federal Budget projects this could total $1.2 trillion over the next decade if current trends continue.

This overpayment stems from two primary mechanisms. First, coding intensity: MA plans document more diagnoses per beneficiary than traditional Medicare physicians, making enrollees appear sicker and increasing risk-adjusted payments. Although CMS reduces MA payments by the statutory minimum of 5.9% to adjust for coding intensity, MedPAC estimates the actual effect is closer to 10-14% higher payments. Second, favorable selection: MA enrollees tend to be healthier than traditional Medicare beneficiaries with similar risk scores. MedPAC estimates this adds 11% to MA costs compared to traditional Medicare, totaling approximately $57 billion in overpayments in 2026.

Of the projected $1.2 trillion in overpayments through 2035, approximately $520 billion will come from the Medicare Hospital Insurance trust fund—nearly as large as the entire HI trust fund deficit. Beneficiaries will pay an additional $220 billion in premiums as a result of these overpayments.

How Medicare Advantage Actually Operates

Medicare pays MA plans based on enrollee risk scores generated through CMS’s Hierarchical Condition Category (HCC) model. This model assigns each beneficiary a risk score based on demographic factors (age, sex, disability status, Medicaid eligibility) and diagnosed medical conditions from the previous year. Higher risk scores generate higher monthly payments.

The fundamental challenge: traditional Medicare doesn’t use diagnosis codes to determine payment. Providers billing fee-for-service Medicare have no financial incentive to document every condition. MA plans, however, directly benefit from comprehensive diagnosis coding—creating what critics call “upcoding” and what the industry defends as “appropriate clinical documentation.”

A 2024 Wall Street Journal investigation revealed that MA plans diagnosed approximately 18,000 enrollees with HIV between 2018 and 2021, but these individuals weren’t receiving HIV treatment from physicians. In many cases, these diagnoses appeared to be added without physician knowledge, raising questions about the accuracy and appropriateness of MA coding practices.

CMS has implemented a new risk adjustment model being phased in over three years (starting at 33% in 2024, increasing to 52% in 2025) to address some coding disparities. This represents a technical adjustment related to medical education costs in the growth rates, but the fundamental incentive structure remains unchanged.

Special Needs Plans and Market Segmentation

Special Needs Plans have become the fastest-growing segment within Medicare Advantage, with enrollment increasing 10% from 2024 to 2025—though this represents a deceleration from the 17% average annual growth rate over the previous five years. SNPs now account for more than one in five MA enrollees.

D-SNPs, which serve beneficiaries eligible for both Medicare and Medicaid, dominate with 83% of SNP enrollment. These plans coordinate benefits across both programs and often provide enhanced care management. However, MedPAC’s analysis excludes the care coordination costs D-SNPs incur when comparing spending to traditional Medicare, potentially overstating the overpayment estimate for this segment.

Chronic Condition SNPs (C-SNPs) saw explosive growth of over 70% between 2024 and 2025, compared to just 3% for D-SNPs and flat growth for institutional SNPs. This reflects both genuine innovation in managing specific chronic conditions and the financial attractiveness of higher risk-adjusted payments for these populations.

Supplemental Benefits as a Competitive Weapon

MA plans use supplemental benefits—services not covered by traditional Medicare—as their primary competitive differentiator. In 2024, 97% of plans offered dental coverage, making it essentially mandatory. More than 86% offered $0 primary care provider copays, recognizing that strong PCP relationships drive better outcomes, lower medical costs, improved Star ratings, and more accurate risk adjustment.

Part B premium buyback plans have increased in prevalence, directly reducing enrollees’ out-of-pocket Medicare premiums. Over-the-counter drug coverage reached 85% of plans, while $0 Part D deductibles appeared in 66% of plans. However, for the first time in years, growth in several supplemental benefits stabilized rather than expanded from 2023 to 2024, reflecting the financial headwinds MA plans faced entering the 2025 bid cycle.

Average value-added benefits (combining Part C medical benefits, Part D drug benefits, and premium reductions) grew approximately $20 per member per month annually from 2021 to 2023, but increased by less than $3 from 2023 to 2024. This deceleration signals a market inflection point where plans are prioritizing margin protection over benefit richness.

Impact on Cost: The $76 Billion Overpayment Question

MedPAC’s methodology compares spending on beneficiaries who switch from traditional Medicare to MA with spending on similar beneficiaries who remain in traditional Medicare. Using data from Medicare “switchers,” MedPAC estimates that MA payments in 2026 will be 22% higher than traditional Medicare would spend for the same population.

Approximately $22 billion of the projected $76 billion in 2026 overpayments stems from coding intensity. MA plans document significantly more diagnoses per beneficiary than traditional Medicare providers, even when the underlying health status appears similar. This isn’t necessarily fraudulent—many MA plans argue they’re simply capturing conditions that exist but weren’t previously documented—but it creates a fundamental payment asymmetry.

The challenge for policymakers: distinguishing between legitimate clinical documentation improvement and aggressive upcoding designed to inflate payments. CMS’s statutory 5.9% coding intensity adjustment has proven insufficient, but determining the “correct” adjustment percentage remains contentious.

Favorable Selection and Healthier Populations

Favorable selection accounts for approximately $57 billion in overpayments in 2026. Despite similar risk scores, MA enrollees consistently spend less on healthcare than traditional Medicare beneficiaries, suggesting they’re healthier than their risk scores indicate.

Several mechanisms drive favorable selection. Prior authorization requirements and narrower provider networks may discourage sicker beneficiaries from enrolling or may reduce utilization once enrolled. MA plans also invest heavily in targeted marketing toward healthier populations and design benefits to attract lower-cost enrollees—for example, gym memberships appeal to relatively healthy seniors while doing little for frail, homebound beneficiaries.

MedPAC’s analysis adjusts for measurable health differences, but critics argue the methodology can’t fully capture the complexity of who chooses MA versus traditional Medicare. More than 40% of MA enrollees join MA plans directly upon Medicare eligibility, bypassing traditional Medicare entirely. If these direct-to-MA enrollees have different cost patterns than the “switchers” MedPAC studies, the overpayment estimates could be either too high or too low.

The Industry Pushback

The MA industry vigorously disputes MedPAC’s overpayment estimates. The Better Medicare Alliance, America’s Health Insurance Plans (AHIP), and the Healthcare Leadership Council have all published analyses challenging MedPAC’s methodology.

Industry arguments focus on three main points. First, MA provides additional value—care coordination, disease management programs, 24/7 nurse hotlines, and wellness benefits—that traditional Medicare doesn’t offer. Comparing costs without accounting for this additional value creates an incomplete picture.

Second, MedPAC’s reliance on “switcher” data creates a biased sample that doesn’t represent the full MA population, particularly the growing share who join MA directly upon eligibility. Third, D-SNPs incur significant care coordination costs mandated by CMS that traditional Medicare doesn’t provide, making direct cost comparisons misleading.

However, these industry critiques don’t directly rebut MedPAC’s core finding: the federal government pays MA plans substantially more than it would pay traditional Medicare for clinically similar beneficiaries. Whether that additional payment purchases sufficient additional value for beneficiaries and taxpayers remains the central policy debate.

Impact on Patient Outcomes and Access

Prior Authorization: 50 Million Requests Annually

Medicare Advantage insurers processed nearly 50 million prior authorization determinations in 2023, averaging 1.8 requests per enrollee. This represents a steady increase from 37 million requests in 2021 as MA enrollment has grown. By comparison, traditional Medicare processed fewer than 400,000 prior authorization reviews in fiscal year 2023—about 0.01 per beneficiary—reflecting traditional Medicare’s limited use of prior authorization for only a narrow set of services like certain durable medical equipment and home health services.

An AMA survey found that practices complete an average of 39 prior authorization requests per physician per week. For physician groups treating substantial numbers of MA patients, this administrative burden is significant. 94% of physicians reported that prior authorization leads to delays in patients accessing necessary care, and 24% reported that prior authorization has led to a serious adverse event for a patient in their care.

The sheer volume creates friction in the healthcare delivery system, even when requests are ultimately approved. Providers must staff dedicated personnel to manage prior authorization, track submissions, follow up on pending requests, and handle appeals—costs that don’t exist in traditional Medicare’s simpler administrative model.

Denial Rates and the Appeal Reality

In 2023, MA plans denied 6.4% of all prior authorization requests—3.2 million denials. While this represents a decrease from the 7.4% denial rate in 2022, it still means millions of provider-ordered services require additional steps before proceeding.

Denial rates vary substantially across insurers. In 2023, Centene denied 13.6% of prior authorization requests while Anthem denied just 4.2%. CVS Health denied 11%, Humana denied 3.5%, and UnitedHealthcare denied 5.9%. These differences reflect varying approaches to medical necessity determination, network management strategies, and benefit design.

Only 11.7% of denied prior authorization requests were appealed in 2023. This low appeal rate likely reflects multiple factors: beneficiaries may not understand their appeal rights, may lack the time or capacity to navigate the appeals process, or may simply pay out-of-pocket or forego the service rather than fight the denial.

However, among denials that were appealed, 81.7% were fully or partially overturned in 2023. This high overturn rate is striking and troubling. It suggests either that MA plans are inappropriately denying care that clearly meets medical necessity standards, or that only the strongest cases proceed to appeal while weaker cases are abandoned. An HHS Office of Inspector General review found that 13% of prior authorization denials by MA plans would have been approved under traditional Medicare coverage rules, and 18% of payment denials met both Medicare coverage rules and MA billing rules yet were still denied.

Post-Acute Care Access Restrictions

A 2024 Senate Permanent Subcommittee on Investigations report found that MA plans deny prior authorization requests for post-acute care at dramatically higher rates than their overall denial rates. In 2022, UnitedHealthcare and CVS denied post-acute care requests at approximately three times their overall denial rates, while Humana’s post-acute care denial rate was more than 16 times higher than its overall denial rate.

This creates particular challenges for hospitals discharging Medicare Advantage patients who need skilled nursing, inpatient rehabilitation, or long-term acute care. Discharge planning teams must navigate plan-specific criteria, obtain prior authorization before transfer, and manage denials that delay transitions of care. When MA plans deny post-acute care that traditional Medicare would cover, hospitals face pressure to keep patients in acute beds longer than medically necessary or to discharge patients without adequate follow-up care.

Examples from the OIG review included MA plans requiring X-rays before approving more advanced imaging like MRIs, and using clinical criteria not contained in Medicare coverage rules to deny services that would have been covered in traditional Medicare. These denials potentially delay necessary diagnoses and treatment, particularly for time-sensitive conditions.

Impact on Healthcare Compliance and Operations

Star Ratings Pressure and Quality Bonuses

CMS’s Five-Star Quality Rating System drives substantial financial stakes. Plans achieving 4 stars or higher receive quality bonus payments that increase their benchmarks, allowing higher bids or more generous benefits. In 2024, quality bonuses totaled at least $12.8 billion.

However, Star ratings have been declining. In 2024, only 31 plans earned 5 stars, down from 57 in 2023 and 74 in 2022. The average Star rating fell from 4.14 in 2023 to 4.04 in 2024 when weighted by membership. Kaiser Permanente, historically a 5-star plan, dropped to 4 stars. This widespread decline reflects both increased performance pressure and changes to the rating methodology that have made high ratings harder to achieve.

MedPAC has criticized the Star rating system as “not a good basis for judging quality,” noting that the measures don’t necessarily correlate with better patient outcomes and that the quality bonus payments contribute to overpayments without clear evidence of proportional quality improvement. Nevertheless, the Star rating system remains central to MA plan operations, driving investments in member engagement, medication adherence programs, and health assessments designed to improve measured performance.

Plans dedicate substantial resources to maximizing Star ratings. This includes member outreach campaigns to complete Health Risk Assessments, medication adherence programs targeting Star-measured drugs, care management interventions for members with care gaps, and strategic provider contracting based on quality performance. These activities may genuinely improve care, but they’re fundamentally motivated by financial incentives rather than pure clinical necessity.

Broker Compensation Changes

CMS attempted to standardize and tighten broker commission limits in the 2025 MA final rule to reduce steering of beneficiaries toward plans that pay higher commissions rather than plans that best meet beneficiaries’ needs. This rule faced legal challenges and implementation has been delayed, but the underlying issue remains: broker incentives don’t always align with beneficiary interests.

In response to ongoing margin pressure, many MA plans have begun reducing or eliminating commissions on new products that may be unprofitable. Plans retain these products to avoid disrupting existing membership, but they don’t pay brokers to actively sell them to new enrollees. This creates a de facto tiering of products: heavily commissioned plans that brokers actively market versus low-commission or zero-commission plans that beneficiaries must proactively seek out.

For health systems with provider-sponsored health plans (PSHPs), this dynamic creates competitive disadvantages. PSHPs, which are predominantly nonprofit plans aligned with health systems, captured only a small fraction of 2024’s MA growth despite theoretical advantages in plan-provider integration. Research shows that 62% of primary care physicians recommend specific health plan products to their patients, and approximately half of patients follow that advice. Yet PSHPs continue to lose market share, suggesting that broker incentives and marketing budgets matter more than physician recommendations in driving enrollment decisions.

Network Adequacy Requirements

CMS’s 2024 final rule strengthened network adequacy standards and transparency requirements. Plans must demonstrate adequate provider networks before the start of the plan year and maintain updated provider directories that accurately reflect which providers are accepting new patients.

This creates both compliance obligations and strategic considerations. MA plans must contract with sufficient specialists in each required category, maintain adequate geographic distribution, and ensure appointment wait times meet CMS standards. However, plans also benefit from selectively narrow networks that channel members toward high-performing, cost-effective providers.

The tension between network breadth and managed care discipline remains central to MA operations. Broader networks may attract more enrollees and reduce access complaints, but they dilute the plan’s ability to steer utilization and negotiate favorable rates. Narrower networks enable tighter cost management but risk beneficiary complaints, network adequacy violations, and Star rating penalties for member experience measures.

For providers, MA network participation has become essential as MA penetration exceeds 50%. Being out-of-network for major MA plans increasingly means being effectively inaccessible to more than half of Medicare beneficiaries in many markets. This gives MA plans substantial negotiating leverage, particularly in less competitive markets where one or two plans dominate.

Common Misconceptions About Medicare Advantage

“MA Is Always Cheaper for the Government”

This is demonstrably false based on current payment structures. MedPAC’s analysis shows Medicare pays MA plans 22% more than it would spend covering the same beneficiaries in traditional Medicare. The Congressional Budget Office projects this will cost taxpayers an additional $1.2 trillion through 2035.

The misconception stems from MA’s origins in the 1990s when the program was sold as a way to harness private sector efficiency to reduce Medicare costs. In practice, payment policies—including quality bonuses, risk adjustment, and insufficient coding intensity adjustments—have created a system where MA costs more, not less.

MA industry advocates argue that cost comparisons should account for additional value: out-of-pocket limits, supplemental benefits, care coordination, and disease management programs that traditional Medicare doesn’t provide. This is a reasonable point for evaluating overall value, but it doesn’t change the underlying cost reality: MA currently costs the federal government substantially more per beneficiary than traditional Medicare.

“MA Plans Have Better Quality”

The evidence is mixed and often contradictory. MA plans point to their Star ratings, supplemental benefits, and care coordination programs as evidence of superior quality. However, MedPAC notes that the Star rating system doesn’t reliably measure clinical outcomes and is susceptible to gaming through selective enrollment and aggressive member engagement campaigns.

Studies comparing MA to traditional Medicare outcomes show inconsistent results. Some research finds MA enrollees receive more preventive care and have better medication adherence. Other studies find no significant differences in mortality, hospital readmissions, or emergency department use. The HHS Office of Inspector General’s finding that 13% of MA prior authorization denials would have been approved under traditional Medicare raises concerns about access to medically necessary care.

The quality debate often conflates different dimensions: access to supplemental benefits versus access to medically necessary services, process measures versus health outcomes, and member satisfaction versus clinical effectiveness. MA likely performs better on some dimensions (financial protection through out-of-pocket limits, access to dental and vision care) while potentially performing worse on others (prior authorization barriers to specialty care, restricted access to post-acute services, narrow networks limiting provider choice).

“Prior Authorization Only Affects a Small Number of Services”

99% of Medicare Advantage enrollees are in plans with prior authorization requirements for at least some services. MA plans processed 50 million prior authorization determinations in 2023—an average of 1.8 per enrollee. For context, traditional Medicare processed only 400,000 prior authorization reviews for its entire population of approximately 29 million beneficiaries.

While not every enrollee personally experiences a prior authorization delay or denial, the system’s pervasiveness affects care delivery broadly. Physicians spend an average of 13 hours per week on prior authorization across all payers. This doesn’t include just the minority of patients facing denials—it includes every request submitted, whether ultimately approved or denied.

The impact extends beyond the headline denial rate. Even approved prior authorizations create delays while awaiting determination, impose administrative costs on providers, and introduce friction into the care delivery process. The 81.7% overturn rate on appeals suggests that many denials were questionable from the outset, meaning patients and providers expended time and effort navigating appeals for services that were always medically necessary.

Traditional Medicare vs. Medicare Advantage: The 2026 Reality

Coverage Differences

Traditional Medicare provides:

• Nationwide provider network (any provider accepting Medicare)
• No prior authorization for most services
• No out-of-pocket maximum on Part A and Part B spending
• Standardized cost-sharing (20% coinsurance for Part B)
• No coverage for dental, vision, or hearing (except medically necessary)
• Separate Part D prescription drug coverage (optional)
• Supplemental Medigap coverage available (at additional premium)

Medicare Advantage provides:

• Restricted provider networks (HMO, PPO, PFFS structures)
• Prior authorization requirements for many services (99% of plans)
• Out-of-pocket maximum ($9,350 cap for in-network services in 2025)
• Varying cost-sharing by plan (often lower copays for primary care)
• Typically includes dental, vision, and hearing coverage
• Integrated Part D prescription drug coverage in most plans
• Additional supplemental benefits (gym memberships, OTC allowances, meal delivery)
• No Medigap allowed (prohibited by law)

Feature	Traditional Medicare	Medicare Advantage (Part C)
Provider Network	Nationwide: Any provider in the U.S. accepting Medicare.	Restricted: Limited to HMO, PPO, or PFFS networks.
Prior Authorization	Generally not required for most services.	Required for many services (99% of plans).
Out-of-Pocket Max	None. No cap on Part A and B spending.	Mandatory Cap: Max $9,350 (2025) for in-network.
Cost Sharing	Standardized (e.g., 20% coinsurance for Part B).	Varies by plan; often lower copays for primary care.
Drug Coverage	Requires separate Part D plan.	Usually integrated into the plan.
Extra Benefits	None (no dental, vision, or hearing).	Includes dental, vision, hearing, gyms, and OTC.
Medigap Eligibility	Yes: Can buy supplemental insurance.	No: Prohibited by law.
Premiums	Part B premium ($185/mo in 2026) + Part D/Medigap.	Often $0 (beyond the standard Part B premium).
Administrative Ease	High (simple billing, no network hurdles).	Lower (requires managing networks and approvals).

Cost Structure Comparison

For beneficiaries, MA often appears less expensive. 75% of enrollees in individual MA plans pay no premium beyond the standard Medicare Part B premium ($185 per month in 2026). Average out-of-pocket limits in MA plans were $4,882 for in-network services in 2024. Traditional Medicare has no Part A and B out-of-pocket limit, making it potentially catastrophic for high utilizers who don’t purchase supplemental Medigap coverage.

However, this favorable cost structure for enrollees comes at taxpayer expense. The federal government pays MA plans an average of 22% more per beneficiary than traditional Medicare would cost. This subsidy enables MA plans to offer generous benefits at low or zero premiums, but it increases overall Medicare program costs and accelerates Medicare Hospital Insurance trust fund insolvency.

For providers, the cost equation differs. Traditional Medicare pays predictable, transparent rates set by CMS fee schedules. MA plans negotiate rates individually, often paying below Medicare rates in competitive markets, and impose prior authorization and other administrative requirements that increase provider costs. Some providers, particularly in specialties facing high prior authorization burdens, are choosing to opt out of MA networks despite the loss of access to more than half of Medicare beneficiaries in many markets.

Access and Administrative Burden

Traditional Medicare offers essentially unlimited access: beneficiaries can see any provider accepting Medicare anywhere in the country without prior authorization or network restrictions. This matters particularly for beneficiaries who winter in different states, travel frequently, or need specialty care at major academic medical centers.

MA access depends on networks and prior authorization. Beneficiaries must generally use in-network providers (except in emergencies) and obtain prior authorization for many services. Out-of-area coverage is typically limited to emergencies and urgently needed care. This creates challenges for beneficiaries with complex conditions requiring subspecialty expertise, particularly when the best providers are out-of-network or located outside the plan’s service area.

Administrative burden falls differently on the two systems. For beneficiaries, traditional Medicare is administratively simple: show your Medicare card, pay your cost-sharing, traditional Medicare handles the rest. MA requires understanding network restrictions, obtaining prior authorizations, and potentially appealing denials.

For providers, traditional Medicare involves straightforward billing against published fee schedules. MA involves negotiating contracts with multiple plans, learning each plan’s prior authorization requirements, tracking network status, and managing denials and appeals. The AMA estimates physicians complete 39 prior authorization requests per week—much of this driven by MA and commercial insurance rather than traditional Medicare.

The Next 12–36 Months: What’s Coming

CBO Projects 64% Penetration by 2034

If current trends continue, nearly two-thirds of Medicare beneficiaries will be enrolled in MA plans within a decade. This represents a fundamental transformation of Medicare from a primarily public program into a predominantly privatized system operating through managed care.

However, several factors could slow or reverse this growth trajectory. Payment pressures are mounting: CMS is phasing in risk adjustment model changes that reduce overpayments, MedPAC is advocating for more aggressive coding intensity adjustments, and bipartisan congressional scrutiny of MA overpayments is increasing. If payment rates decline meaningfully, plans may reduce benefit generosity, exit less profitable markets, or restrict enrollment—all of which could dampen growth.

Demographic factors continue favoring MA growth. Approximately 10,000 baby boomers turn 65 daily, a pattern that will continue through 2030. More than 40% of new Medicare eligibles now join MA directly rather than starting in traditional Medicare, suggesting generational acceptance of managed care that wasn’t present in earlier cohorts. This direct-to-MA enrollment pattern, if it continues, will sustain growth even if switching from traditional Medicare to MA slows.

Regulatory Pressure on Overpayments

Multiple federal bodies are now focused on MA overpayments. MedPAC publishes annual overpayment estimates and advocates for payment reforms. The HHS Office of Inspector General conducts audits of MA plan practices and recommends policy changes. Congressional committees particularly the Senate Permanent Subcommittee on Investigations have held hearings and published reports documenting inappropriate denials and excessive coding.

The political dynamics are complex. MA enjoys strong beneficiary satisfaction enrollees appreciate low premiums, out-of-pocket limits, and supplemental benefits. This creates political resistance to major payment cuts that might reduce benefit generosity. However, fiscal pressures are mounting. The Medicare Hospital Insurance trust fund faces insolvency projections, and MA overpayments represent a significant contributor. The Committee for a Responsible Federal Budget estimates that MA overpayments will extract $520 billion from the HI trust fund through 2035.

Potential regulatory changes include:

• More aggressive coding intensity adjustments above the current 5.9% statutory minimum
• Reformed risk adjustment models that better account for favorable selection
• Restrictions on supplemental benefits that primarily attract healthy enrollees
• Enhanced prior authorization oversight and denial reporting requirements
• Reduced or reformed quality bonus payments
• Benchmark adjustments in overpaid counties

Market Consolidation Among Top Payers

Market concentration continues increasing. UnitedHealth Group, Humana, and CVS (Aetna) collectively enrolled 794,000 new members in 2024 out of 1.3 million total market growth more than 60% of all new enrollment. Looking at full-year 2024 data, Humana lost 259,000 members and Centene lost 87,000 members, while the top three national plans captured essentially all growth.

This concentration creates both opportunities and risks. For large national plans, scale enables investments in care management infrastructure, data analytics, provider contracting leverage, and Star rating improvement programs. For smaller regional plans, Blues plans, and provider-sponsored health plans, competing becomes increasingly difficult without comparable scale advantages.

Provider-sponsored health plans continue losing market share despite theoretical advantages in plan-provider integration. In 2024, PSHPs (predominantly nonprofit plans aligned with health systems) failed to capture meaningful growth. This suggests that distribution advantages—large broker networks, national brand recognition, and aggressive marketing budgets—matter more than care integration in driving enrollment.

The consolidation trend will likely continue absent significant regulatory intervention. MA plans benefit from network effects and scale economies that favor large, established players. This raises questions about long-term market structure: will MA evolve into an oligopoly dominated by three or four national plans, or will niche players find sustainable positions serving specific geographies or populations?

Practical Takeaways for U.S. Healthcare Leaders

For Health System Executives:

1. Develop MA-specific strategies – With MA exceeding 50% penetration in most markets, you cannot treat MA as an afterthought in strategic planning. Network contracting, care delivery models, and financial projections must explicitly account for MA’s distinct characteristics.
2. Invest in prior authorization management – The administrative burden of 50 million annual prior authorization requests is real and growing. Dedicated staff, workflow optimization, and potentially technology solutions are necessary to manage this efficiently.
3. Understand payment mechanics – Risk adjustment and coding matter enormously to MA plan financial performance. Health systems with value-based contracts or risk-sharing arrangements must understand HCC coding, documentation requirements, and risk score management.
4. Monitor post-acute care denials – If you operate skilled nursing facilities, inpatient rehab, or LTACHs, pay close attention to denial rates by plan. Denials that are three to sixteen times higher than overall rates create real financial and operational challenges.

For Payer Leaders:

5. Prepare for payment pressure – The $76 billion overpayment estimate and $1.2 trillion ten-year projection are not going away. Regulatory changes targeting overpayments are likely within the next 12-36 months. Bid strategies must account for potential benchmark reductions and tighter coding intensity adjustments.
6. Balance growth and margin – The era of unlimited benefit reinvestment to drive membership growth is ending. Financial sustainability requires more intentional ROI analysis on supplemental benefits and member retention strategies.
7. Navigate Star rating volatility – With ratings declining broadly and 5-star plans dropping from 74 in 2022 to 31 in 2024, maintaining high ratings will become harder and more expensive. Evaluate whether maximum Star pursuit remains cost-effective or whether a 4-star strategy provides better financial returns.

For Policy-Aware Operators:

8. Track regulatory developments – CMS rulemaking, MedPAC recommendations, and congressional investigations will drive significant changes. Prior authorization reforms, network adequacy standards, and payment methodology changes will all affect operations.
9. Document defensive positions – When prior authorization denials occur for services that meet Medicare coverage rules, maintain careful documentation. The 81.7% appeal overturn rate suggests opportunities to challenge inappropriate denials systematically.
10. Consider traditional Medicare’s advantage – Traditional Medicare’s administrative simplicity—no prior authorization, nationwide network, predictable payment—has value that isn’t fully reflected in enrollment trends. For some patient populations and provider types, traditional Medicare may offer better alignment despite MA’s financial generosity.

Medicare Advantage has become the dominant form of Medicare coverage, enrolling 54% of eligible beneficiaries and projected to reach 64% by 2034. This shift represents a fundamental restructuring of Medicare from a public fee-for-service program into a predominantly private managed care system.

However, this transformation comes with substantial costs and tradeoffs. Federal overpayments totaling $76 billion in 2026 projected to reach $1.2 trillion through 2035 raise serious questions about value and sustainability. Prior authorization burdens affecting 50 million requests annually, denial rates that disproportionately impact post-acute care, and coding practices that inflate risk scores without corresponding service delivery all warrant scrutiny.

For healthcare leaders, the strategic imperative is clear: you must understand Medicare Advantage deeply – its payment mechanics, operational requirements, regulatory trajectory, and market dynamics. This is no longer optional as MA transitions from an alternative program to the primary form of Medicare coverage. Success in this environment requires adapting care delivery, contracting strategies, and operational capabilities to MA’s fundamentally different structure while maintaining sustainable economics in an environment of increasing payment pressure and regulatory scrutiny.

The next 12-36 months will be defining. Payment reforms targeting over-payments, enhanced scrutiny of prior authorization practices, and continuing market consolidation will reshape the MA landscape. Organizations that anticipate these changes and position strategically will thrive; those that treat MA as simply “more Medicare” will face growing challenges.