Washington, D.C. — The Centers for Medicare & Medicaid Services (CMS) is stepping up requirements for Medicare Advantage (MA) plans by mandating comprehensive data reporting on coverage denials and appeals. This move follows a CMS pilot program and is intended to bring greater transparency to the process, according to agency materials and industry reporting.
New Rules on Data Reporting
Beginning in 2026, all MA plans will be required to provide detailed information on their initial coverage decisions and the ensuing appeals, under a rule finalized by CMS. This requirement intends to highlight potential patterns in coverage denials, offering insights into the practices of MA providers. The decision underscores CMS’s commitment to ensuring fair treatment of Medicare beneficiaries, especially in the realm of skilled nursing care.
Independent Appeals Process Introduced
In addition, a rule finalized by CMS establishes an independent appeals process for certain post-acute care services, including skilled nursing, intended to aid both beneficiaries and long-term care providers. This rule addresses longstanding concerns about the bureaucratic hurdles providers face when appealing denied coverage, with sector leaders hailing it as a vital support for those “stuck in the middle.”
Senate Scrutiny
Amid these regulatory changes, a recent U.S. Senate report criticized the three largest Medicare Advantage insurers for allegedly limiting access to post-acute care services, including skilled nursing. The report suggests that such limitations force beneficiaries into making difficult choices regarding their care.
Industry Impact
These developments are seen as significant steps toward enhancing transparency in the MA landscape, which now covers more than half of all Medicare beneficiaries, according to federal enrollment data. By shedding light on denial patterns, CMS aims to improve accountability among insurers and better support nursing homes and other post-acute care providers.
