Health Plan Accountability Update: October 2025

Top News

AHA urges Aetna to rescind ‘level of severity inpatient payment’ policy

The AHA Sept. 15 urged Aetna to rescind its recently announced “level of severity inpatient payment” policy, saying that it “could erode the transparency consumers rely on to make informed decisions about their care, undermine important regulatory protections that safeguard patients’ coverage, and jeopardize the ability of hospitals to provide high-quality, accessible care to all who need it.”

Effective Nov. 15, Aetna will create a new type of inpatient reimbursement for so-called “low severity” inpatient stays that it has said will be “comparable” to observation rates. This policy will take the place of Aetna’s (and essentially every other insurer’s) long-standing approach of denying inpatient stays it deems medically unnecessary and then, in most instances, downgrading them to outpatient observation status. Instead, Aetna will approve these inpatient stays but reimburse hospitals at a lower rate it determined unilaterally outside of the good faith contract and rate negotiation process. This policy only will apply to Aetna’s Medicare Advantage and dual eligible lines of business.

The letter discusses the impact the policy could have on beneficiaries’ and regulators’ ability to assess the quality of Aetna’s coverage; how it could circumvent established regulatory standards regarding coverage for Medicare Advantage beneficiaries; and “further stress an already financially unstable health care system at a time when hospital costs for caring for patients continue to rise.”

HHS announces expansion of health coverage access through new hardship guidance

The Department of Health and Human Services Sept. 4 announced new hardship exemption guidance that would allow consumers ineligible for premium tax credits or cost-sharing reductions to enroll in catastrophic health coverage. Consumer eligibility will be based on projected annual household income. The Centers for Medicare & Medicaid Services made this change in light of the significant anticipated rise in individual market premiums and the expiration of the enhanced premium tax credits at the end of the year.

AHA participates in roundtable with CMS administrator at AtlantiCare in NJ

Centers for Medicare & Medicaid Services Administrator Mehmet Oz, M.D., July 19 visited AtlantiCare health system in New Jersey, making stops at its medical facilities, regional educational institutions and community outreach sites. After the tour, Oz met with leaders from health care, government, education and technology to discuss how evolving federal policy intersects with the day-to-day delivery of care — and the need for reforms that improve access and reduce complexity. AHA Senior Vice President of Public Policy Analysis and Development Ashley Thompson participated in the roundtable, which included a discussion about technology opportunities and regulatory relief, referencing recommendations from the AHA to streamline operations and ease administrative strain.

AHA TV, digital ad urges Congress to protect access to hospital care

The AHA June 23 launched a new ad urging Congress to protect access to hospital care as it considers legislation that could have far-ranging negative consequences for patients, communities and hospitals across America. The ad highlights how, when every second counts, America’s hospitals and health systems are there 24/7 to care for patients during life’s moments. The campaign includes a TV ad that will run on broadcast and cable TV in Washington, D.C., as well as digital ads.

Prior Authorization

AHA provides recommendations to HHS, CMS for insurers to adhere to prior authorization pledge

The AHA Sept. 29 sent recommendations to the Department of Health and Human Services and the Centers for Medicare & Medicaid Services to help ensure insurance plans adhere to the agencies’ health insurer pledge to reform prior authorization processes. They include monitoring plans’ progress in fully implementing existing regulations, such as the interoperability and prior authorization final rule and reforms issued in the 2024 Medicare Advantage final rule. “As a result of the enormous detrimental impact that certain prior authorization practices routinely place on patients, physicians and hospitals, the AHA has been actively pushing for reforms in this area for a long time and working with health plans to collaboratively reduce the burdens associated with these programs,” the AHA wrote.

Medicare Advantage News

AHA-supported legislation would apply prompt payment standard to MA plans

The AHA expressed support Sept. 22 to House and Senate sponsors of the Medicare Advantage Prompt Pay Act (H.R. 5454/S. 2879), legislation that would apply a federal prompt payment standard to MA plans to help ensure that health care providers receive timely payments from MA plans for necessary patient services. The measure calls for plans to pay at least 95% of clean claims within 14 days for in-network claims and 30 days for out-of-network claims. MA plans would face civil monetary penalties if they miss any deadlines and would have to publicly report compliance data, including the number of claims paid on time.

Study: MA beneficiaries’ hospital stays longer than patients under Traditional Medicare

A JAMA internal medicine study published Sept. 8 found that since the COVID-19 pandemic, Medicare Advantage beneficiaries have been experiencing longer hospital stays than patients under Traditional Medicare. The study examined more than 89 million hospitalizations from 2017 to 2023 and found the average length of stay for MA admissions during that period increased from 6 to 7.1 days, while Traditional Medicare admissions grew from 5.8 to 6.3 days. The researchers noted that these trends “may reflect insurance-related discharge barriers” and that the results “are consistent with hospital industry reports.” They point to prior authorization or limited post-acute care networks as possible causes.

Study finds less than 40% of Medicare beneficiaries with OUD receive standard care

A Health Affairsstudy (published Sept. 2 found that less than 40% of Medicare beneficiaries with opioid use disorder received standard care in alignment with quality measures. Researchers analyzed Medicare enrollment, claims and encounter data to assess the extent to which beneficiaries with OUD received treatment in alignment with eight nationally recognized quality measures in 2020. The study found that Medicare Advantage performed worse than fee-for-service Medicare on six of eight measures, and that Medicare performed worse than Medicaid on all three comparable OUD quality measures available.

AHA supports bill expanding in-network providers within MA plans

The AHA Sept. 15 expressed support for the Ensuring Access to Essential Providers Act, legislation that would require Medicare Advantage plans to cover services provided by certain essential community providers, including different types of hospitals that the plans must negotiate with to include in their network. The bill would increase the number of in-network providers within MA plans.

Study shows Medicare Part D changes could lead to higher cost sharing for some beneficiaries

A JAMA study published Aug. 18 found that plan design changes by Medicare Part D insurers, particularly for Medicare Advantage plans, following passage of the Inflation Reduction Act of 2022 could lead to higher cost sharing for some beneficiaries who do not reach the $2,000 out-of-pocket maximum for prescription drug coverage in 2025. Researchers said policies prevented premium increases in 2025, but Part D plans may have responded by increasing deductibles or medication cost sharing. The study found mean deductibles for MA plans decreased from $153 in 2019 to $66 in 2024, before sharply increasing to $228 for 2025. Additionally, the proportion of MA beneficiaries with coinsurance for preferred brand-name drugs ranged from 0.8% to 2.5% from 2019 to 2024, before increasing to 27.7% in 2025.

Rules and Regulations

AHA shares concerns to CMS on CY 2026 home health PPS rule

The AHA Aug. 28 expressed concerns to the Centers for Medicare & Medicaid Services on the calendar year 2026 home health prospective payment system proposed rule. The AHA said that proposed budget neutrality reductions to the HH base payment rate would compound access challenges for beneficiaries needing HH care and disrupt operations for acute care and other hospitals. The AHA urged CMS to suspend the proposed cuts in favor of more adequate payment updates. Additionally, the AHA recommended CMS take other actions, including reassessing and refining the HH market basket construction approach, reexamining the impacts of the productivity adjustment on Medicare payments, and addressing harmful practices of Medicare Advantage plans that restrict acute care hospital capacity and delay timely access to post-acute care.

From the AHA

Perspective: Holding Commercial Health Insurers Accountable

AHA president and CEO Rick Pollack wrote Oct. 3 about AHA’s efforts to protect patients’ health and ensure that medical professionals, not the insurance industry, are making the key decisions in patient care. READ MORE

Perspective: Gearing Up for a Busy Fall as We Urge Congress to Support Hospitals and Protect Access to Care

AHA president and CEO Rick Pollack wrote Sept. 5 on the legislative priorities AHA will be taking to Capitol Hill this fall. READ MORE

Legislation and Legislative Activity 

AHA Details Legislative Priorities for Congressional Leaders 

Statements, Letters and Advisories

LETTER: AHA Supports House Medicare Advantage Prompt Pay Act (H.R. 5454)

LETTER: AHA Supports Senate Medicare Advantage Prompt Pay Act (S. 2879)

LETTER: AHA Supports the Ensuring Access to Essential Providers Act of 2025

REGULATORY ADVISORY: Inpatient PPS Final Rule for FY 2026

ACTION ALERT: Ask Lawmakers to Protect Access to Care, Support Hospitals

LETTER: AHA Expresses Support for Senate Preserving Patient Access to Accountable Care Act

LETTER: AHA Expresses Support for House Preserving Patient Access to Accountable Care Act

STATEMENT: AHA Statement on House Ways and Means Committee Hearing on Medicare Advantage

REGULATORY ADVISORY: Hospital Outpatient, Ambulatory Surgical Center Proposed Rule for CY 2026

LETTER: AHA Opposes House Bill Proposing to Expand Physician-owned Hospitals

LETTER: AHA Urges Senate to Amend Budget Reconciliation Bill to Protect Access to Care 

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.