ACP calls for Medicare Advantage transparency overhaul

The American College of Physicians is calling on the CMS to reform Medicare Advantage to restore program integrity, promote more transparency and protect patients against high healthcare costs and limited healthcare access, the ACP wrote in a recent position paper in Annals of Internal Medicine.

Medicare Advantage, the private option in Medicare operated by private insurers, integrates Medicare Parts A and B of traditional Medicare, plus some additional coverage for prescription drugs, dental and vision.

But the Medicare Advantage landscape is opaque, the ACP continued, with limited transparency in plan choices that makes it hard for members to select the right plan for their needs. Add in problems with unexpected costs and prior authorization, and the ACP contended that Medicare Advantage can disadvantage members who are low-income, live in rural areas or have multiple chronic conditions.

Still, Medicare Advantage is the most common Medicare plan of choice, covering more than half of all Medicare enrollees. To ensure equitable and sustainable access to Medicare Advantage, the ACP suggested the CMS look into program overhauls that address transparency, misleading marketing tactics and prior authorization requirements.

For example, the ACP stressed more transparent and standardized benefit designs to help consumers make informed enrollment decisions. Benefits should be based on health promotion, the ACP added.

Furthermore, the CMS must ensure transparent marketing of Medicare Advantage plans, including more robust oversight and regulation of marketing practices.

Next, the ACP called for clearer cost disclosures and better practices to ensure access to care and support healthcare affordability.

While data has shown that Medicare and Medicare Advantage enrollment help insulate seniors from high healthcare costs, members tend to have high medical complexity that can contribute to financial strain, especially when living on a fixed income. Per a 2023 study in Health Affairs, about a quarter of older adults face at least one healthcare affordability challenge.

Relatedly, a better system for Medicare Advantage risk adjustment will help better reflect the medical complexity of the populations these plans serve. The CMS uses risk adjustment to reimburse Medicare Advantage plans based on the mix of patients they enroll. The higher the risk, the higher the reimbursement rate.

This process has been fraught, with analyses finding that big Medicare Advantage players like UnitedHealthcare and Humana are gaming the risk adjustment system, according to a 2025 report from the Alliance for Community Health Plans. The report contended that plans mine patient charts to find additional diagnoses, misrepresenting a higher-risk beneficiary pool to get additional payments from the CMS.

Earlier this year, the CMS unveiled a proposal to exclude chart reviews from Medicare Advantage risk adjustment in 2027, which could address this tactic.

The ACP indicated that some changes to Medicare Advantage risk adjustment need to be made to restore integrity to the program.

Notably, the ACP urged changes to Medicare Advantage prior authorization practice. Across payer types, prior authorization has been a thorn in patients' and providers' sides, with many indicating it limits patient access to care.

Although prior authorization has been regarded as a key utilization management and cost containment strategy for payers, the ACP said faster response times and improved transparency are necessary.

Next, the ACP called for adding telehealth benefits to Medicare Advantage plans, as well as a deeper look into the impacts of supplemental benefits to promote accountability.

And finally, the organization urged healthcare policymakers to consider Medicare Advantage contracts. Some models currently impact how physicians can serve their patients, but the ACP concluded that policies should prioritize patient-centered care over financial considerations.

Although the ACP focused on program reforms to promote the integrity of the Medicare Advantage program, the organization cautioned against letting traditional, fee-for-service Medicare fall into the rearview. Program changes must protect traditional Medicare and prevent Medicare Advantage from becoming a de facto privatized version of Medicare.

Sara Heath has reported news related to patient engagement and health equity since 2015.