Medicare Advantage Denials Under Federal Scrutiny: What You Need to Know

If you're enrolled in a Medicare Advantage plan and your doctor has ever ordered a test, procedure, or specialist visit that the plan refused to cover, you are not alone — and you are not powerless. Federal regulators have been paying close attention to a pattern that has frustrated millions of seniors: Medicare Advantage insurers denying care that traditional Medicare would almost certainly have approved. This issue has moved from the pages of patient advocacy reports into the halls of Congress and the offices of federal enforcement agencies, and the consequences for insurers — and the protections for you — are growing.

Medicare Advantage, also called Medicare Part C, is an alternative to original Medicare offered by private insurance companies. In 2024, according to CMS.gov data, more than 33 million Medicare beneficiaries were enrolled in Medicare Advantage plans, representing roughly 54% of all Medicare-eligible individuals. The program has grown dramatically over the past decade because many plans offer $0 premiums, dental and vision benefits, and prescription drug coverage bundled into one card. But that growth has come with a troubling side effect: the use of prior authorization — a process where the insurer must approve a service before it's provided — has become a significant barrier to care for many enrollees.

The HHS Office of Inspector General released a landmark report finding that Medicare Advantage organizations denied prior authorization requests at a rate that, in a substantial share of cases, involved services that met Medicare coverage rules. In plain terms: insurers were saying no to care that the federal Medicare program would have said yes to. The OIG found that some denials were based on internal clinical criteria that went beyond what Medicare itself requires — criteria that beneficiaries and even their doctors often had no way of knowing existed. This is not a minor administrative hiccup. When a prior authorization for a post-acute skilled nursing stay is denied, a senior recovering from hip surgery may be sent home before they are medically ready. When a diagnostic imaging request is rejected, a potential cancer diagnosis can be delayed by weeks or months.

CMS has responded with a series of regulatory actions designed to rein in these practices. Starting in 2024, CMS implemented new rules requiring Medicare Advantage plans to base coverage decisions on Medicare's national and local coverage determinations — not on the plan's own, often more restrictive, internal guidelines. Plans are also now required to make prior authorization decisions faster: 72 hours for urgent requests and 7 calendar days for standard requests, down from previous timeframes that could stretch to 14 days. These are not suggestions. Plans that fail to meet these timelines face civil monetary penalties. CMS has also increased audit activity, conducting more targeted audits of high-denial-rate plans and publishing the results in ways that affect a plan's star rating — which in turn affects how much bonus payment the plan receives from the federal government.

Understanding your rights as a Medicare Advantage enrollee starts with knowing the appeals process, which has multiple layers and specific deadlines. If your plan denies a service — either before you receive it (a prior authorization denial) or after (a claim denial) — the plan must send you a written notice called an Adverse Coverage Determination. This notice must explain exactly why the service was denied and must include instructions for how to appeal. Your first step is to file a Level 1 appeal, also called a redetermination, directly with your Medicare Advantage plan. The plan must respond within 60 days for standard appeals or 72 hours for expedited appeals involving urgent medical situations. Critically, if your doctor certifies that waiting the standard timeframe could seriously jeopardize your health, you are entitled to the faster expedited review — and you should ask for it in writing.

If the plan upholds its denial at Level 1, you move to Level 2: a review by a Qualified Independent Contractor (QIC), which is an organization that has no financial relationship with your insurer. This is where many denials get overturned. Data from the Medicare Appeals System has consistently shown that beneficiaries who appeal — particularly those who reach the independent review stage — win a significant portion of their cases. The problem is that most beneficiaries never appeal at all. According to KFF analysis, fewer than 1% of denied Medicare Advantage claims are ever appealed. That means billions of dollars in legitimate care goes unprovided simply because enrollees don't know they can fight back, or feel too overwhelmed to try. If you are denied care you believe is medically necessary, filing an appeal is one of the most important things you can do — and you have the right to have a family member, friend, or patient advocate help you do it.

For beneficiaries who feel the appeals process is too slow or too complicated, there is another option worth knowing: the expedited grievance. This is different from an appeal. A grievance is a formal complaint about how your plan is treating you — including delays, poor customer service, or failure to provide required notices. You can file a grievance and an appeal simultaneously. You can also contact 1-800-MEDICARE (1-800-633-4227) at any time to report a problem with your plan, and Medicare staff can help you understand your options and escalate your case if necessary. The Medicare Rights Center (medicarerights.org) also offers free counseling for beneficiaries navigating denials and appeals.

The federal scrutiny of Medicare Advantage denials has also put a spotlight on a specific practice called "step therapy" or "fail first" protocols. Under these protocols, a plan may require you to try a less expensive drug or treatment before it will approve the one your doctor actually prescribed. While step therapy is legal in Medicare Advantage, CMS rules require that plans allow exceptions when the required first-step treatment is contraindicated, has already been tried and failed, or when the delay would cause serious harm. If your plan is requiring you to try a medication your doctor says is inappropriate for your condition, you have the right to request a step therapy exception — and your doctor's supporting documentation is your strongest tool in making that case.

Data Snapshot: According to CMS.gov data from the 2024 Medicare Advantage landscape files, there were approximately 7,900 Medicare Advantage plan options available nationwide for the 2024 plan year, spanning HMO, PPO, PFFS, and SNP plan types. Among those plans, CMS star ratings showed that roughly 37% of enrollees were in plans rated 4 stars or higher — a metric that CMS uses as a proxy for quality and member experience, including how well plans handle appeals and grievances. Plans rated below 3 stars for two consecutive years can face enhanced oversight and, in some cases, contract termination. This rating system gives beneficiaries a meaningful tool: before enrolling in or renewing a Medicare Advantage plan, checking its star rating at Medicare.gov/plan-compare can reveal how the plan has historically performed on care access and member complaints.

If you are currently in a Medicare Advantage plan and experiencing repeated denials, you are not locked in permanently. During the Annual Enrollment Period — which runs October 15 through December 7 each year — you can switch to a different Medicare Advantage plan or return to original Medicare. If you return to original Medicare, you may want to add a Medicare Supplement (Medigap) policy to cover costs that original Medicare doesn't pay, such as hospital coinsurance and the Part B deductible (which is $240 in 2024). Be aware that in most states, if you are returning to original Medicare after being in a Medicare Advantage plan for more than 12 months, Medigap insurers can use medical underwriting and may deny you coverage or charge higher premiums based on your health history. There are exceptions: if you are within your first 12 months of a Medicare Advantage plan, you have a guaranteed issue right to buy certain Medigap policies without underwriting.

There is also a Medicare Advantage Open Enrollment Period that runs January 1 through March 31 each year. During this window, you can switch from one Medicare Advantage plan to another, or drop your Medicare Advantage plan and return to original Medicare. You cannot, however, use this period to switch from original Medicare into a Medicare Advantage plan. Knowing these windows matters because if your plan is denying care and you are approaching the end of the year, you may want to document your denial history carefully and use the Annual Enrollment Period to move to a plan with a better track record.

For beneficiaries who want to be proactive rather than reactive, there are several practical steps worth taking before a denial ever happens. First, when you enroll in a Medicare Advantage plan, ask for the plan's prior authorization list — a document that specifies which services require advance approval. This list is publicly available and your plan is required to provide it. Second, when your doctor recommends a procedure or specialist referral, ask the office staff to verify authorization with your plan before the appointment is scheduled. Third, keep a written log of every interaction with your plan, including the date, the name of the representative you spoke with, and what was said. This documentation can be invaluable if you need to escalate an appeal. Fourth, if you have a complex medical condition, consider asking your State Health Insurance Assistance Program (SHIP) counselor — a free, unbiased resource available in every state — to review your plan's coverage rules with you annually. You can find your local SHIP counselor at shiphelp.org.

The federal attention being paid to Medicare Advantage denials is a signal that the regulatory environment is shifting in favor of beneficiaries. But regulations only protect you if you know they exist and know how to invoke them. The most important thing any Medicare Advantage enrollee can do is treat a denial not as a final answer, but as the opening move in a process that the law has specifically designed to give you a fair hearing.