The American Health Care Association (AHCA) is re-releasing its Medicare Advantage (MA) data initiative for 2025, following its initial launch in 2024. AHCA members are asked to share Medicare Advantage data using
this tool for August 2025 (8/1-8/31/25) and/or September 2025 to support continued efforts to assess how plans are implementing new regulations, particularly those related to prior authorizations for skilled nursing facility (SNF) care. The revised tracking tool includes administrative costs associated with these authorizations and appeals.
Please refer to the instructions tab for guidance on reporting and submission. All submissions will be de-identified and aggregated before sharing them with a PAC Coalition and policymakers to support continued advocacy for MA reforms and ensure beneficiary access to medically necessary post-acute care. Please reach out to AHCA Population Health Policy Analyst
Rohini Achal with any questions.
This initiative aligns with ongoing federal oversight and growing attention to Medicare Advantage practices. A recent Centers for Medicare and Medicaid Services (CMS) 2024 audit and enforcement report, as well as a July Congressional hearing, underscore the importance of collecting timely data to inform advocacy and policy efforts.
CMS Audit and Enforcement Report
CMS conducted 39 total (routine and focused) program audits covering 494 contracts, covering 69% of the combined Parts C and D populations. Key areas of noncompliance included:
- Delays and inaccuracies in coverage determinations and appeals.
- Inadequate beneficiary communication and documentation.
- Deficiencies in compliance program oversight.
Audits spanned seven compliance areas, including program effectiveness, formulary administration, care coordination, and other administrative processes. Notably, CMS conducted a first-time review of MAO’s implementation of the new Part C utilization management requirements effective January 1, 2024.
CMS evaluated whether MAOs:
- Followed national and local Medicare coverage policies.
- Used internal coverage criteria (ICC) appropriately when Medicare guidance was unclear.
- Avoided denying services for medical necessity if they had already been approved via prior authorization.
- Ensured adverse decisions were reviewed by qualified clinical professionals.
- Made internal coverage criteria publicly available.
- Established Utilization Management Committees (UMCs) to oversee UM policies.
While CMS found general adherence, it emphasized that findings are preliminary – as this was the first year of implementation and auditing under the new rules.
Congressional Hearing
The House Ways and Means Committee held a
joint Health and Oversight Subcommittee hearing on July 22 to examine lessons learned from over two decades of the MA program. Overall, bipartisan leaders agreed that Medicare Advantage is a strong and valuable program – but also acknowledged that meaningful improvements are needed to address ongoing challenges and ensure it works effectively for beneficiaries and providers alike.
Members raised issues around prior authorization denials and upcoding, with witnesses calling for greater transparency and streamlined processes. The discussion highlighted challenges in how incentives are structured within MA plans and emphasized the need for a more preventative, patient-centered approach across the health care system.