Washington, D.C. — In case you missed it, the largest Medicare Advantage Organizations (MAOs) have denied requests for skilled nursing and other post-acute care at high, disproportional rates, according to an alarming report released from the Office of Inspector General (OIG) last week. Overall, OIG findings show that MAOs denied 40 percent of requests for skilled nursing-level care, compared to just 11 percent for all other enrollees. This disparity raises serious concerns about MAO practices and seniors’ access to necessary post-acute care.
In addition, OIG identified high overturn rates when denials for skilled nursing facility (SNF) care were appealed. Although only 18 percent of SNF denials were appealed, MAOs overturned these denials 95 percent of the time in favor of the Medicare Advantage enrollee, suggesting initial denials were inappropriate and that SNF care was medically necessary. Enrollees who appealed SNF denials typically waited an average of six days for a decision, with 17 percent waiting 10 or more days. These long wait times prolonged hospital stays and forced seniors to pause their recovery.
“OIG’s findings confirm what the skilled nursing community has been saying for years: that large, insurer-led Medicare Advantage plans too often deny and delay access to care, but especially post-acute care,” said American Health Care Association and National Center for Assisted Living (AHCA/NCAL) President and CEO Clif Porter. “It’s unconscionable that insurers are making frail seniors and their families jump through numerous hoops at a critical time for their recovery.”
The reports also spotlight widespread concerns with certain contractors. Specifically, the contractor naviHealth, a subsidiary of United Health Group, Inc., processed half of all SNF admission requests and denied 14 percent, significantly higher than internal MAO processing (11 percent) and other contractors (9 percent). When appealed by enrollees, MAOs overturned 97 percent of naviHealth's denials.
Not all MAOs employ these inappropriate practices. Small, provider-led plans like Institutional Special Needs Plans (I-SNPs) typically make care decisions in partnership with each patient, their medical team, and families. I-SNPs have also been shown to improve primary care, care planning, care coordination, and ultimately, health outcomes for beneficiaries.
To protect seniors in Medicare Advantage plans from large MAOs that are financially motivated, AHCA/NCAL supports the Medicare Advantage Improvement Act of 2026. This bill focuses on addressing issues surrounding prior authorizations, prompt pay, payment clawbacks and transparency to ensure Medicare Advantage plans deliver on the promise to provide seniors with access to the medically necessary care they need.
AHCA/NCAL President & CEO Porter added, “It is time for lawmakers to act and hold these large Medicare Advantage organizations accountable. Our nation’s seniors deserve timely, consistent access to care, pure and simple.”
Read the full reports: