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Copyright 2026, American Health Law Association, Washington,
\nDC. Reprint permission granted.<\/p>\n
As of 2025, 54% of all Medicare beneficiaries were enrolled in
\nMedicare Advantage (MA).54 The average Medicare
\nbeneficiary had a choice of over 42 options in which to enroll in
\n2025, and the total number of plans was over 3,700 across the
\nUnited States (albeit a 6% decrease from 2024).55<\/p>\n
Like other sectors of health care, however, the future of MA and
\nMedicare Advantage Organizations (MAOs) may be uncertain. Each of
\nthe three main MA stakeholders\u2014MAOs (the plans and payers),
\nenrollees (the Medicare beneficiaries enrolled in MA plans), and
\nthe providers and suppliers (and vendors) who provide items and
\nservices to MA beneficiaries\u2014are facing headwinds that may
\nresult insignificant changes to the program’s operations.
\nAdditional headwinds come from the political uncertainty about
\nhealth care policy in general and reorganizations at CMS.<\/p>\n
Below is a summary of key challenges facing each category of MA
\nstakeholders for the coming year.<\/p>\n
MAOs. Several regulations and policies have been under
\nreview by the Trump administration, including those relating to
\nheath equity and social determinants of health, and several items
\nin CMS’ MA Proposed Rule did not appear in the Final Rule,
\npotentially requiring redirection of MAO emphasis and efforts but
\nalso perhaps cost savings. Proposed changes to agent and broker
\noversight were not finalized.56 MAOs remain subject to
\nRisk Adjustment Data Validation (RADV) audits, but a decision
\nissued in September 2025 ruled in favor of an MAO and vacated the
\nRADV rule that allowed extrapolation of overpayment results. The
\ngovernment has appealed the decision to the Fifth Circuit.<\/p>\n
Supplemental Benefits Vendors. MA plans are required to
\nprovide the same “basic benefits” as are covered under
\ntraditional Medicare and may provide an additional array of
\n“supplemental benefits” that make a particular plan
\nappealing to categories of beneficiaries. While supplemental
\nbenefits were originally limited to “health-related
\nbenefits,” most commonly dental, vision, and hearing services,
\nin2019 CMS expanded the definition to include home health aides,
\ncare giver support, adult daycare services, and therapeutic
\nmassage. In addition, Special Supplemental Benefits for Chronically
\nIll allow MAOs to offer additional benefits that have a reasonable
\nexpectation of improving or maintaining an enrollee’s health or
\noverall function. At least two of the largest MA providers
\nreportedly have announced they will pare back supplemental benefits
\nin 2026, resulting in revenue challenges for the vendors of
\nsupplemental services.57<\/p>\n
Providers. Clinical providers of services to MAOs have
\nlong been frustrated by their relationships with MA plans, and as
\nreported, several prominent providers stopped participating in
\nspecific payer networks or accepting their plans as
\ncovered.58 Reasons for strained relationships include
\npoor reimbursement, difficult prior authorization practices, and
\nslow payment schedules. Moreover, providers may be liable for
\nclaims submitted both by and to the MAO. For example, providers may
\nbe named as defendants in civil False Claims Act cases if they fail
\nto comply with MAO coverage and payment rules specific to that MAO
\n(all 3,700 of them), for which they received payment from the MAO
\n(who received payment from Medicare).59 DOJ identified
\nat least one medical group and related parties as defendants in a
\ncase alleging falsification of diagnosis codes to increase payments
\nto an MAO.60<\/p>\n
Enrollees. As noted above, the total number of plan
\noptions for enrollees has decreased, albeit still seemingly
\nadequate. Although the CMS Calendar Year 2024 Final Rule clarified
\nseveral important provisions designed as beneficiary protections,
\nconcerns continue to percolate, particularly with respect to the
\nMAOs’ approach to utilization management, which may increase
\nwait time for services or deny them altogether. Some MAOs are
\ncutting popular supplemental benefits. In other words, enrollees
\nmay face fewer plan choices with fewer benefits. In 2025, MA
\npayments are 20% more per person than for similar beneficiaries in
\ntraditional Medicare, potentially capturing the focus of CMS or
\nCongress for cuts in MAO payments that will lead to reduced
\nservices provided to enrollees.<\/p>\n
Takeaways. While the United States continues to
\nstruggle to find its way to adequate and cost-efficient health
\ncare, stakeholders including MAOs, beneficiaries\/enrollees, and
\nproviders and vendors may face more immediate changes in the year
\nto come.<\/p>\n
Footnotes<\/p>\n
54. Nancy Ochieng et al., Medicare Advantage in 2025:
55. Meredith Freed et al., Medicare Advantage 2025
Kaiser Family Found. (Nov. 15, 2024), https:\/\/www.kff.org\/medicare\/medicare-advantage-2025-spotlight-a-first-look-at-plan-offerings\/#:~:text=Number%20of%20Plans%20Available%20to%20Beneficiaries.,only%20available%20to%20select%20populations.<\/a><\/p>\n 56. CMS, Agent Broker Compensation, https:\/\/www.cms.gov\/medicare\/health-drug-plans\/managed-care-marketing\/medicare-marketing-guidelines\/agent-broker-compensation.<\/a><\/p>\n 57. Nona Tepper, Medicare Advantage plans edge away from
58. Jakob Emerson, Hospitals are dropping Medicare
\nEnrollment Update and Key Trends, Kaiser Family Found. (July 28,
\n2025), https:\/\/www.kff.org\/medicare\/medicare-advantage-enrollment-update-and-key-trends\/.<\/a><\/p>\n
\nSpotlight: A First Look at Plan Offerings,<\/p>\n
\nsupplemental benefits, Modern Healthcare (Sept., 25, 2025), https:\/\/www.modernhealthcare.com\/insurance\/mh-medicare-advantage-supplemental-benefits-2026\/?utm_content=article1-readmore&utm_source=modern-healthcare-am&utm_medium=email&utm_campaign=20250925.<\/a><\/p>\n
\nAdvantage plans left and right, Becker’s Hosp. Rev. (Sept.27,
\n2023), https:\/\/www.beckershospitalreview.com\/finance\/hospitals-are-dropping-medicare-advantage-left-and-right.html<\/a>
\n(Nov. 13, 2023).<\/p>\n