More than half of all Medicare beneficiaries are now enrolled in Medicare Advantage (MA) and that shift is reshaping how Washington thinks about health care. Policymakers at CMS and in Congress are paying closer attention than ever, because the program isn’t just big: it’s expensive, complicated and raising some tough questions about access and costs. Legislators have pointed to estimates from the Medicare Payment Advisory Commission (MedPAC) and other reports showing that Medicare overpays MA plans compared to traditional Medicare. A letter from Reps. Warren and Jayapal (co-signed by 76 legislators) noted that these payments could total as much as $1.2 trillion over a decade. The Government Accountability Office (GAO), along with hospitals nationwide, have also noted issues with prior authorization limiting access to timely care. As MA enrollment continues to grow, we expect further policymaking impacting the program.  

Why are policymakers wanting to make changes to the MA program? 

The main issues being raised are upcoding leading to overpayments, inadequate prior authorization denials, aggressive marketing practices, and the quality of care. MA plans earn bonuses for high star ratings, but MedPAC says the program costs taxpayers about 22% more per enrollee than traditional Medicare—an extra $84 billion a year. A big chunk of that is tied to rebates, which have ballooned 300% since 2018. The problem is that it’s hard to tell how much of this extra money is actually improving care, and how much is just padding plan benefits or administrative costs. CMS also recently announced that per capita spending in MA is projected to grow faster than in traditional fee-for-service Medicare, at 10.72% versus 8.81%. 

Perhaps the most concerning issue is access to care after a hospital stay. Research shows MA enrollees get fewer home health visits, shorter episodes of care, and worse outcomes compared with people on traditional Medicare. MedPAC reports MA patients receive 11% fewer home health visits overall. This is especially tough for rural hospitals and vulnerable populations, where fewer visits can mean slower recoveries and higher readmissions. At the same time, home health agencies are under pressure from payment cuts, flat Medicare updates, and tough negotiations with MA plans, leaving the sector in a fragile spot. 

Another major concern is the use of prior authorization. Policymakers, providers, and patient advocates have raised alarms that prior authorization often delays medically necessary care, particularly for vulnerable patients being discharged from hospitals. Hospitals have reported that lengthy authorization processes are keeping patients in hospital beds longer than necessary, driving up costs, and increasing the risk of complications. 

What are policymakers doing? 

All of this has regulators stepping up oversight. For example, CMS tried to cap how much brokers could make from selling MA plans but a federal court tossed that out, letting brokers continue to earn market-rate commissions.  

In Medicare’s quality programs, CMS is gradually adjusting its quality metrics to capture the MA population and make hospitals accountable for their care. CMS is starting to consider – what rules that currently apply to fee-for-service should also apply to the MA space? 

CMS is also expanding its risk adjustment audits from just 60 plans to all 550, trying to get a handle on the $17 billion a year in improper payments tied to questionable coding (using certain codes to make patients look sicker). OIG reports have shown how billions in extra payments flow from diagnoses pulled from health risk assessments or chart reviews that never show up in actual medical services.  

CMS is phasing in a revised risk adjustment model called “V28” through 2026. Although implemented to achieve more accurate risk adjustment, the model inadvertently excludes several chronic conditions. For example, diabetes and congestive heart failure are two diseases in which the Hierarchical Condition Category (HCCs) are “constrained” in V28, meaning that all diabetes and congestive heart failure cases carry the same weight, regardless of complications. This means that providers are getting paid the same for those patients, no matter their acuity. This is an issue that AHPA has raised to both CMS and Congress.  

Meanwhile, Congress is also trying to improve how MA plans evaluate patients’ health risks and considering a bill, the “UPCODE Act.” If passed, the bill could negatively impact health care providers. The bill, among other things, excludes patient diagnoses identified through “chart reviews” and “health risk assessments.” Risk adjustment would also rely on two years of diagnoses instead of one. The bill was initially introduced in 2023 and is being considered again for potential inclusion in an end-of-year legislative package.  

On prior authorization, CMS announced that beginning on October 1, 2025, it will begin automating parts of the process, which is expected to speed up approvals for common services. While this is a positive step, AHPA remains concerned that the new policy doesn’t impose financial penalties on plans that fail to comply with new prior authorization requirements, leaving providers and patients at risk of continued delays. Rep. Greg Murphy (R-NC) has introduced a bipartisan bill that AHPA supports, which would streamline prior authorization and require MA payers to reimburse providers at the same rates as traditional Medicare. “Doctors who see MA beneficiaries not only experience major delays in reimbursement and senseless prior authorization denials, but often receive less compensation for services rendered than they earn through traditional Medicare,” Rep. Murphy said in his announcement.  

Put all of this together, and you get a picture of a program that’s grown faster than Washington was ready for. On one hand, MA is popular with seniors and is often marketed as more affordable and flexible. On the other, it’s raising real concerns about costs, fairness, and whether patients are getting the right care once they leave the hospital. CMS and Congress are clearly moving toward tighter rules, closer audits, and tougher scrutiny on quality. For providers, the challenge will be staying ahead of these shifts while continuing to push for fair payment and adequate access for patients, especially in areas like home health where the gaps are already visible.