Health Plan Accountability Update: April 2026

Top News

White House releases health care plan

The White House released a health care plan Jan. 15 addressing drug prices, health insurance premiums and price transparency efforts. The plan includes codifying the administration’s “most favored nation” agreements recently reached with certain drugmakers, where companies must offer Americans the lowest cost paid for the same medications in other countries. It also calls for sending subsidies directly to Americans instead of insurance companies and funding cost-sharing reductions to reduce premiums. The plan would also require health insurers to publish rate and coverage comparisons on their websites “in plain English — not industry jargon” for consumers. In addition, the plan calls for any health provider or insurer accepting Medicare or Medicaid to “prominently” post their pricing and fees.

Analysis: MA insurers made 53 million prior authorization determinations in 2024  

A KFF analysis released Jan. 28 found that Medicare Advantage insurers made nearly 53 million prior authorization determinations in 2024, an increase from 49.8 million in 2023. The report found that MA insurers fully or partially denied 4.1 million (7.7%) of prior authorization requests they received in 2024, and that 11.5% of all denials were appealed. Of those, the initial denial was overturned in 80.7% of cases, similar to figures from previous years. 

Survey finds prior authorization viewed as greatest hurdle in navigating health care

A KFF survey  published Feb. 2 found that people view prior authorization as the biggest challenge beyond costs when navigating the health care system. In terms of issues people viewed as a “major burden,” prior authorization was highest at 32%, followed by understanding their bill or what they owe at 23%. Prior authorization was also considered the “single biggest burden” before accessing certain tests, treatments or medication. Additionally, among individuals with a chronic condition requiring ongoing medical treatment, 39% said prior authorization was the largest burden, more than twice as much as any other issue mentioned.  

Commercial health insurer CEOs testify on health care affordability; AHA submits statements for House hearings

The House Energy and Commerce Subcommittee on Health and Ways and Means Committee  Jan. 22 hosted hearings on health care affordability that included testimony from leaders of five major commercial health insurers: Stephen Hemsley, CEO of UnitedHealth Group, David Joyner, chairman and CEO of CVS Health, Gail Boudreaux, president and CEO of Elevance Health, David Cordani, president, CEO and chairman of the board of The Cigna Group, and Paul Markovich, president and CEO of Ascendiun. Both hearings focused on rising health care costs and access challenges under commercial coverage. The AHA shared statements with both committees that discussed the current landscape of affordability and how the insurance market has driven health care costs upward.   

Among other topics, the AHA highlighted how horizontal and vertical integration increased profits for insurers while increasing health care costs, and how insurers' excessive use of prior authorization to delay and deny coverage harms patients and providers. The AHA also made a series of recommendations to Congress to improve health care affordability, including prior authorization reform, creating prompt payment standards for MA plans and increasing network adequacy standards, especially in post-acute care. READ MORE

Medicare Advantage News

Report finds increasing concentration in commercial health, MA insurance markets

The American Medical Association Dec. 16 released its latest annual report on health insurance competition, finding that 97% of commercial markets were highly concentrated in 2024. In 91% of metropolitan statistical area markets, at least one insurer had a commercial market share of 30% or greater, while in 47% of MSAs, one health insurer held a market share of at least 50%. The report also found that 97% of Medicare Advantage markets were highly concentrated last year. In 90% of MSAs, at least one insurer held an MA market share of 30% or greater, while in 24% of MSAs, one insurer’s MA market share was at least 50%.  

Blue Cross Blue Shield plans held the largest market commercial shares in metro areas, with Elevance having the single largest insurer share at 21%. Among MA plans, UnitedHealth Group was the largest insurer by market share in 44% of MSAs. 

Study finds nearly 3 million MA beneficiaries forced to find alternative coverage for 2026

A JAMA study published Feb. 18 found that 10% of Medicare Advantage beneficiaries — approximately 2.9 million — have needed to find other health coverage for 2026 due to MA plans leaving the market. This increased from 6.9% in 2025. The report found that those needing to find alternative coverage were more likely to be enrolled in preferred provider organization plans, non-special needs plans, small carrier plans and lower star-rated plans, and live in rural areas in markets with lower MA penetration. Drivers of increased MA plan exit could include changes to plan payments and risk adjustment, along with unanticipated increases in coverage use among MA enrollees, the study noted. 

Perspective: Providing Solutions to Address Challenges with MA Plans

In his Feb. 6 Perspective column, AHA president and CEO Rick Pollack wrote on the AHA’s advocacy for strengthening federal oversight of MA programs, as well as recommendations the AHA has made to the Centers for Medicare & Medicaid Services to ensure that program rules and oversight mechanisms will better serve beneficiaries, providers and taxpayers.   

AHA comments on proposed Medicare Advantage, Part D payment changes for CY 2027

The Centers for Medicare & Medicaid Services Jan. 26 released proposed changes to Medicare Advantage plan capitation rates and Part D payment policies for calendar year 2027, which the agency estimates will result in a net average year-over-year increase of 0.09% in MA plan payments, or $700 million. CMS proposes to address coding differences between MA and Original Medicare, in addition to updating the MA risk adjustment model to reflect current costs associated with various conditions and characteristics. The agency also proposes to exclude diagnosis information from unlinked chart review records from risk score calculation in CY 2027 and solicits feedback on new measures that would incentivize plans from providing unnecessary, inappropriate or low-value care, as well as measures related to medical errors or misdiagnoses. CMS also plans updates to the Part D risk adjustment model. Out-of-pocket prescription drug costs for individuals with Medicare Part D are proposed to be capped at $2,400 in 2027, up from $2,100 in 2026. Comments on the CY 2027 proposals were due Feb. 25. The agency expects to publish a final rate announcement on or before April 6. 

The AHA Jan. 26 expressed support and provided its perspective on certain provisions of the proposed rule, including revisions to the special enrollment period for provider terminations, medical loss ratio and network adequacy reporting processes and data collections, the MA quality rating system (Star Ratings), reductions to regulatory burden and other matters related to the future of the MA program.

MedPAC recommends Medicare 2027 payment updates to Congress for inpatient, outpatient services

The Medicare Payment Advisory Commission Jan. 15 voted to recommend that Congress update Medicare payment rates for hospital inpatient and outpatient services by the current law amount for 2027 and reiterated its recommendation to distribute an additional $1 billion to safety-net hospitals by transitioning to a Medicare safety-net index policy. The AHA Jan. 9 urged the commission for higher updates.

In other action, MedPAC recommended that Congress update 2027 Medicare payments for physicians and other health professional services by current law plus 0.5%. The commission also recommended reducing the 2027 payment rates for home health agencies by 7%, skilled nursing facilities by 4% and inpatient rehabilitation facilities by 7%. The commission also presented status reports for the Part D program, the Medicare Advantage program and ambulatory surgical centers.

UHG launches pilot program for rural hospitals in 4 states to cut MA payment collection times by half

UnitedHealth Group announced Jan. 14 that it launched a six-month pilot program to reduce Medicare Advantage payment processing times by half for rural hospitals in four states. The program, called the Rural Payment Acceleration Pilot, seeks to reduce payment timelines from less than 30 days to less than 15, on average. The company said participating hospitals were selected “through criteria intended to maximize impact and guide future rural-focused solutions.” UHG said it would share the program’s progress with providers, policymakers and community stakeholders.

Senate report says UHG used ‘aggressive strategies’ to increase MA payments

A Senate Judiciary Committee report released Jan. 12 found that UnitedHealth Group used “aggressive strategies” to maximize its Medicare Advantage risk-adjustment scores and collect higher payments from diagnoses of MA enrollees. The report said that UHG appeared to leverage its size, vertical integration and data analytics to stay ahead of CMS’ efforts to counteract unnecessary spending related to coding practices. “After a review of the records, this report provides evidence that shows UHG has turned risk adjustment into a major profit centered strategy, which was not the original intent of the program,” the report said.

CMS releases form for submitting provider complaints on Medicare Advantage plans

The Centers for Medicare & Medicaid Services has implemented an online form for providers to submit complaints regarding Medicare Advantage plans. A CMS memorandum issued Dec. 22 announced implementation of the form. Subsequently, CMS has stated that all provider complaints should be submitted using the form effective Jan. 5, 2026. The form requests basic information about the complainant, beneficiary, provider, the Medicare Advantage plan and a complaint summary and provides optional fields for dates of service and the claim number.

OTHER NEWS

CMS issues proposed notice of benefit and payment parameters for 2027

The Centers for Medicare & Medicaid Services Feb. 9 released its 2027 proposed standards for the health insurance marketplaces, including the issuers and brokers who assist marketplace enrollees. Notably, the proposed rule would allow CMS to certify non-network health plans as qualified health plans, beginning in plan year 2027. The proposed rule also would repeal the standardized plan options and would allow states to establish a new exchange option known as the State Exchange Direct Enrollment option. Many of the policies proposed build on changes finalized in the 2025 Marketplace Integrity and Affordability rule. CMS is accepting comments for 30 days following publication in the Federal Register. 

House subcommittee hearing discusses impacts of drug pricing on health care costs

The House Energy and Commerce Subcommittee on Health Feb. 11 hosted a hearing titled “Lowering Health Care Costs for All Americans: An Examination of the Prescription Drug Supply Chain”.  The AHA provided a statement for the hearing that shared concerns on issues such as efforts to weaken the 340B Drug Pricing Program, drug shortages and other drug supply chain disruptions, and private-payer policies undermining access and patient safety. The AHA made a series of recommendations to Congress, including opposing efforts to move 340B pricing to a rebate model, enacting policies to improve medication and device access, and prohibiting private-payer policies that require hospitals to obtain clinician-administered drugs through insurer-selected specialty pharmacies rather than through their own hospital pharmacy systems. 

Perspective: Working to Ensure Commercial Health Insurers Do Their Part to Support Patient Care

AHA President and CEO Rick Pollack wrote in his Jan. 16 Perspective column about how AHA advocates with Congress, the administration, regulatory agencies and insurers for needed reforms, including alleviating burdensome policies and practices that can add costs and delay care.

AHA urges Elevance Health to rescind Anthem’s ‘Nonparticipating Provider Policy,’ citing harm to patient care access

The AHA Dec. 17 urged Elevance Health, which is the parent company of the Anthem brand of health plans, to rescind Anthem’s nonparticipating provider policy that is set to go into effect Jan. 1, citing the harm it will inflict on patients.

Effective Jan. 1, 2026, Anthem intends to impose punitive measures on hospitals participating in the plan’s network in instances where an out-of-network provider is part of an Anthem enrollee’s care team. Under the policy, Anthem could penalize hospitals equal to 10% of the allowed amount of the hospital’s claims that involve the use of an out-of-network provider and potentially terminate the hospital from its networks. Penalties and termination can be applied to hospitals under the policy even though hospitals may not own, control or manage independent providers involved in a patient’s care. READ MORE

NEW RESOURCES

White paper explains use of mock claims for advanced explanation of benefits

The AHA Jan. 26 released a white paper on addressing challenges in implementing an advanced explanation of benefits, which requires coordination among multiple providers, health plans and IT systems. It highlights the use of a mock claim proposal, which uses the same electronic format providers already use to submit insurance claims to transmit good faith estimates to health plans. These estimates would be submitted as mock versions of real claims to estimate care costs, allowing health plans to process them using existing adjudication systems and generate an AEOB for patients. READ MORE 

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.