Medicare Advantage – Standards


When administered properly, private health plans can oversee patient care effectively and discourage unnecessary use of services. Private plans receive the same level of reimbursement (based on the number and type of enrollees) regardless of the number of services they provide. Thus, participating providers may have incentives to deliver less care than needed. Safeguards must ensure that a plan’s cost controls do not adversely affect access to, or the quality of, enrollee care and that Medicare resources are used properly. 

Medicare Advantage (MA) plans are required to cover all services covered by Traditional Medicare Parts A and B except hospice care. However, MA plans may not cover the cost of services that they determine not to be medically necessary under Medicare. Beneficiaries can ask the MA plan for a written advance coverage decision to make sure that it will be covered. If the plan determines the service is not medically necessary, the beneficiary may have to pay all of the costs. The beneficiary retains the right to appeal the plan’s decision. Depending on the type of plan, MA plans may also have other insurance rules limiting access to care that do not exist in traditional Medicare. These rules may include, for example, prior authorization requirements before receiving certain services or referral requirements before seeing a specialist. A 2022 report by the Health and Human Services’ Office of the Inspector General raised concerns about MA plans delaying or denying access to medically necessary care that would otherwise be covered under traditional Medicare. 

MA enrollees also have the right to an independent review of plan decisions, including an expedited appeal within 72 hours of asserting that their condition requires rapid review. Each fall during Medicare’s Annual Open Enrollment Period (between October 15 and December 7), Medicare beneficiaries may choose or change MA plans, switch to traditional Medicare, and elect a Medicare prescription drug plan. Since 2019, MA enrollees have also had the option to switch MA plans between January 1 and March 31 during a period known as the MA Open Enrollment Period. During the enrollment period, MA enrollees may also switch to Traditional Medicare and elect a stand-alone Medicare prescription drug plan. However, in many cases, beneficiaries who switch from MA to traditional Medicare during these enrollment periods may not be able to obtain a Medicare Supplement insurance policy. This is because of the medical underwriting requirements of these policies, also known as Medigap (see also Medicare Supplemental Insurance).

All Medicare beneficiaries—including those in MA plans—need assurances that the program has strong quality-of-care standards and other consumer protections in place. 

In its oversight capacity, the Centers for Medicare & Medicaid Services can terminate a private plan’s Medicare contract or impose intermediate sanctions, including monetary penalties, if warranted.



Federal standards

All participating health plans in the Medicare program must be initially certified as having met the federal standards designated by the Centers for Medicare & Medicaid Services (CMS). They must be subject to federal oversight to ensure ongoing compliance with the standards. 

Financial stability

All participating health plans must be financially sound. Financial standards should contain solvency requirements, including for capital reserves, which take into account the plan’s level of risk and service-delivery capabilities. Capital reserves should be set at adequate levels to protect beneficiaries in the event of a plan’s insolvency. 

Access to emergency care

In the event of an emergency, enrollees in Medicare Advantage (MA) plans with networks should not be required to obtain care through the plan’s provider network. Emergency care must be defined using the “prudent layperson standard.” That is, coverage for emergency care should include the provision of services where the enrollee presents to a provider outside the health plan with symptoms, including severe pain, that a prudent layperson would reasonably believe to be an emergency medical condition. 

Health plans should be contacted to determine follow-up treatment once MA enrollees who present to emergency departments are stabilized. The plan should be prepared to assume the care of the patient. 

Patients should be covered for all necessary care associated with the emergency. Health plans should be prohibited from requiring prior authorization for emergency services. The special needs of people with mental illness and substance abuse should be taken into account when coverage decisions are made concerning emergency services or urgently needed care. 

Comprehensive information in marketing materials

Federal authorities must approve all marketing materials before their use. 

Health plans should be required to provide standardized information to prospective and new enrollees, including: 

  • information on benefits, limitations, exclusions, restrictions on use of services, and plan ownership; and 
  • a summary of physicians’ financial incentive arrangements, written in terms that an average beneficiary will understand. 

Health plans should also be required to share: 

  • the stability and composition of the provider-and-practitioner network, including a list of the participating physicians and hospitals with their credentials and licensing data; 
  • disclosure of any sanctions imposed by CMS or any other regulatory body due to a plan’s failure to comply with statutory and regulatory requirements; 
  • information about whether practitioners are accepting new patients; 
  • comprehensive information on patients’ experience with care in the plan and the plan’s clinical performance (as measured by the Consumer Assessment of Healthcare Providers and Systems and the Healthcare Effectiveness Data and Information Set, respectively), and the performance of participating physicians, hospitals, skilled-nursing facilities (SNFs), home health agencies, and pharmacies; and 
  • whether and at what level the plan is accredited by a national organization whose standards have been deemed acceptable by CMS, disenrollment rates from the plan (including reasons for leaving the plan), and data on grievances and appeals filed by beneficiaries. 

Materials must be written at a sixth-grade reading level or lower. They must be available in languages other than English when the plan serves or will serve substantial numbers of enrollees whose native language is not English. And the materials must be culturally appropriate for the enrolled population. Marketing presentations implying that a beneficiary’s failure to enroll will result in the loss of Medicare entitlement must be prohibited. Other prohibited marketing activities should include door-to-door solicitation, offering beneficiaries inducements to enroll, and discriminatory activities designed to recruit healthier-than-average enrollees. 

Appropriate enrollment practices and procedures

All enrollment in Medicare private health plans should be conducted by a third-party contractor. No health plan should be permitted to enroll beneficiaries directly. 

All health plans—including fee-for-service, MA, and Medigap insurers—should be required to participate in an annual, coordinated open enrollment period. During this period, plans must accept all eligible applicants without regard to their health status, previous claims experience, medical history, or lack of evidence of insurability, to the extent the plan capacity will allow as determined by CMS

In order to avoid discriminating against population groups based on their place of residence, plans should serve a complete market area. 

The federal government should improve transparency and oversight of the so-called seamless enrollment arrangements approved by the Centers for Medicare & Medicaid Services (CMS). This allows insurers to automatically enroll individuals from Medicaid managed care and private plans into the same insurer’s MA plan once those individuals reach Medicare eligibility. CMS should limit approval of such enrollment arrangements only into the highest-performing MA plans. The federal government should provide consumers affected by these arrangements with clear notice about the existence and implications of the arrangement and ensure that consumers have an effective ability to opt out. 

The federal government should ensure that the implementation of seamless enrollment arrangements to MA plans—from Medicaid managed care and private insurance plans—does not interfere with consumers’ right to choose Traditional Medicare coverage or access to Medigap coverage during their initial open enrollment period. 

Ability to disenroll

Medicare beneficiaries enrolled in MA plans should be able to disenroll for any reason and at any time—effective the first day of the following month—and to enroll in the Traditional Medicare program. 

Medigap insurers should be required to sell insurance coverage without medical underwriting to any beneficiary who applies for supplement coverage after disenrolling from an MA plan. 

Education and guidance

Training should be available to state Medicaid program personnel to help them understand the Medicare program. This allows them to make informed decisions about enrolling duals in coordinated care programs. 

Fair rates and payments

Premiums charged by health plans participating in Medicare must be community-rated for the Medicare population. Payments to plans should be risk-adjusted so that payment reflects the risk undertaken on behalf of the beneficiaries enrolled. 

Current Medicare balance-billing limitations should apply to all Medicare-covered services provided to Medicare beneficiaries for care in and out of the network. 

Accessibility and network adequacy

Health plans must be able to demonstrate that appropriate and necessary services are reasonably available and accessible 24 hours a day, seven days a week. Health plans must have sufficient numbers of practitioners, providers, and facilities, with sufficient distribution of providers by specialty and location within the plan’s service area to serve enrolled members. 

The adequacy of a network should be assessed in relation to the health plan’s model type, the prevailing patterns of provider distribution in the plan’s geographic service area, and the needs of the plan’s enrollees. 

Women should have direct access to obstetricians and gynecologists. They should be allowed to designate these medical professionals as their primary care providers. 

Health plans should contract with Advanced Practice Registered Nurses and other non-physician providers.  

Health plans should be required to refer beneficiaries to specialists affiliated with the plan or to recognized specialty-care centers affiliated with the plan pursuant to treatment plans. 

Referrals should include provisions for standing referrals, as determined by the referring practitioner in consultation with the health plan. Health plans should be required to provide out-of-network referrals at no additional cost to the enrollee if the plan does not have a network physician with appropriate training and experience. It should also do so if it has no affiliation with a recognized specialty-care center that can meet an enrollee’s covered medical needs. Patients with mental disorders should receive appropriate referrals to mental health specialists. 

Continuity of care

CMS should prohibit health plans from altering provider networks during the enrollee lock-in period. However, if a plan does terminate providers during this period, enrollees whose physicians have been terminated without cause should be given adequate time to find a new provider. When a plan’s mid-year provider terminations are substantial, CMS should provide enrollees with a special enrollment period to select another MA plan or return to Traditional Medicare. Health plans should facilitate care coordination and the transition to new providers. 

Providers should be given adequate notice of mid-year, no-cause terminations. Also, to facilitate continuity of care, health plans must notify affected enrollees at least 90 days before the termination of a provider, as long as the termination is not for cause. When termination is for cause, affected enrollees should be notified as soon as possible of the departure of their provider and should be given information about how to obtain a new provider. 

Enrollees with serious care needs should be able to receive covered, medically necessary care from their specialist provider for up to 90 days (or through postpartum) after the provider has been dropped. Covered enrollees should include those undergoing an active course of treatment for a life-threatening or degenerative and disabling conditions. It should also apply to enrollees who have entered the second trimester of pregnancy at the effective date of enrollment. Coverage should continue through postpartum. This coverage extension should apply to enrollees if their employer drops a plan that includes the patient’s treating physician specialist and to existing enrollees if their previous physician specialist is terminated by the health plan for reasons other than cause. 

Private health plans should be encouraged to coordinate their services with long-term care services and support providers, particularly for people with chronic conditions. 

Utilization review/utilization management

Written clinical review criteria must be developed with the involvement of health plan practitioners. They must be made available to plan practitioners and enrollees. 

Utilization review (UR) and utilization management (UM) plans must be designed to detect underutilization as well as overutilization. 

Adverse UR decisions must be made by clinically qualified personnel and reviewed by active practitioners in the same or similar specialty. Reviewing clinicians need not be residents of the state where the enrollee whose claim is being reviewed resides. Reviewers must not receive financial compensation based directly or indirectly on the number or volume of certification denials. 

Certification decisions must be made at least as rapidly as the medical situation requires to protect the beneficiary’s health and permit a meaningful appeal. Denials must be accompanied by clear information on the reasons for denial as well as instructions on how to appeal the denial. 

Private health plan liability

All private health care plans should be held accountable for their actions. If a health plan has been involved in a decision to delay or deny needed health care services, the plan should be liable for any injuries or harm an enrollee may sustain. 

The right to seek meaningful judicial redress for decisions that contributed to injury or death should be available to all MA enrollees regardless of the source of their health care coverage. In cases where state laws on the corporate practice of medicine prevent holding managed care organizations accountable for harm caused by inappropriate treatment decisions, those laws should be revised to afford the injured enrollee access to state court. 

Coverage for experimental services

Health plans should have an objective and expeditious process for considering experimental treatments, including new drugs, devices, procedures, and therapies. 

Health plans should be required to participate in an external, independent review of coverage denials. Reviews should be conducted by a panel of experts selected by an impartial, independent, and accredited entity. 

Coverage for care in clinical trials

Enrollees in private health plans should have appropriate access to, information about, and protections within clinical trials. Private health plans should cover routine patient care costs (e.g., hospital services, physician services, and diagnostic tests) associated with plan enrollees’ participation in clinical trials that are: 

  • funded by the National Institutes of Health (NIH), the Centers for Disease Control and Prevention (CDC), the Agency for Healthcare Research and Quality (AHRQ), CMS, the Department of Defense (DOD), or the Department of Veterans Affairs (VA); 
  • supported by centers or cooperative groups funded by CMS or the NIH, CDC, AHRQ, or DOD; or 
  • sponsored by the VA and conducted under an investigational new drug (IND) application reviewed by the Food and Drug Administration (FDA), exempt from needing an IND application under FDA regulations, or deemed by CMS to meet the qualifying criteria developed by the appropriate multiagency federal panel. 

These services should be covered even if the provider participating in the clinical trial is not part of the managed care organization’s network. However, some services related to clinical trials need not be covered by the managed care organization. These include investigational item or service itself as well as items and services provided solely to satisfy data collection needs or provided by the trial sponsor without charge. 

Credentials for clinicians and practitioners in health plan networks

Each practitioner must be credentialed before participating in a health plan and recredentialed every two years. 

The medical director or other plan representative authorized to act on the plan’s behalf must be responsible for the credentialing process. 

There must be a credentialing committee with representation of plan practitioners. 

Credentialing information must be subject to review and correction by the practitioner being credentialed. 

Information about the credentialing process and policies must be available for review by providers and enrollees upon request. Information on practitioner credentials must be available to plan enrollees. 

The plan must obtain primary verification of current license, malpractice coverage, hospital privileges, board certification (if any), Drug Enforcement Administration certificate, medical degree, and residency training, as well as secondary verification of license, malpractice, and National Practitioner Data Bank history. 

The plan also must conduct an on-site office visit and review of medical record-keeping practices. For recredentialing, in addition to all the procedures required for initial credentialing, the plan must review member complaints, results of quality assurance and utilization review activities, and member-reported experiences of care. 

Provider-and-practitioner contracting

Plans should be required to provide services through contracts with providers and practitioners. If a health plan denies a physician’s application to participate, terminates its agreement with the physician, or suspends its contract with the physician, the plan should provide the physician with a written explanation for the action and afford the physician the right to appeal. 

Contracts should encourage open communication between providers and enrollees concerning all treatment options and other issues concerning patients’ health care. Each contract should clearly identify the services to be provided and include provisions that: 

  • hold enrollees harmless for payment of covered services in the event of nonpayment by the health plan; 
  • require continuation of covered services to enrollees throughout the period for which a premium has been paid, regardless of the health plan’s insolvency or nonpayment; 
  • prohibit the collection of any payments (other than required cost-sharing) from enrollees for covered services provided by the practitioner or as a result of the practitioner’s authorized referral; 
  • prohibit balance billing; 
  • require the practitioner to participate in and cooperate with quality assurance and utilization review activities of the health plan and of federal agencies conducting external quality reviews; 
  • prohibit any physician incentive plan that directly or indirectly bases payment on the reduction or withholding of medically necessary services to enrollees; 
  • require medical records to be maintained in an appropriate manner; 
  • insist providers or practitioners report specified data; and 
  • require the practitioner or provider’s office or facility to be subject to inspection by the plan. 

Coordination of hospice coverage

Hospice care is ordinarily covered through the Traditional Medicare Part A program. Enrollees in MA plans and their family caregivers should receive clear information about how hospice care will be covered. 

Hospice care for beneficiaries enrolled in MA plans should be integrated. If proposals for MA plans to cover hospice benefits directly are considered, such proposals should ensure that the hospice benefit retains a person- and family-centered approach that provides quality end-of-life care to beneficiaries as well as services and support for their families. 

Such proposals would be best undertaken in a broad, multiyear demonstration. 

Any such demonstration should be exhaustively examined to ensure that: 

  • the hospice benefit received by those enrolled in MA is the same or better compared with the benefit covered by Traditional Medicare; 
  • MA plans cover the full scope of the Medicare hospice benefit; 
  • no additional cost-sharing should be permitted beyond what is allowed under Traditional Medicare; 
  • beneficiaries and their families are not adversely impacted, including enrollees of color and enrollees with low incomes; and 
  • quality metrics and payment incentives are designed to encourage appropriate levels of access, beneficiary choice, and positive care experiences for beneficiaries and family caregivers. 


Private health plans must prevent the improper use or release of personally identifiable medical information. The security of all data and personal health information, including electronic information, must be ensured. Appropriate protections and procedures must be adopted in the event the confidentiality of personal health information is breached (see this chapter’s section Privacy, Confidentiality, and Security of Health Information). 

Data collection and reporting

All health plans serving Medicare beneficiaries must collect and report comparable, independently audited data to demonstrate compliance with national standards. 

Health plans must collect and report: 

  • medical costs or expenditures on a per capita basis by type of expenditure (physician, inpatient, outpatient, home health, skilled-nursing facility, etc.); 
  • plan administration costs; 
  • complaints and grievances, as well as their resolution; 
  • physician satisfaction; 
  • health care quality as assessed by performance on standardized measures including the performance of participating physicians, hospitals, SNFs, home health agencies, and pharmacies, and beneficiaries’ experience with care; 
  • credentialing; 
  • utilization management or appeals regarding the use of out-of-plan services; 
  • accessibility and the number of practitioners accepting new patients; 
  • rates of physician turnover; 
  • enrollment and disenrollment rates; and 
  • data on race, ethnicity, and language preference. 

The government should increase its analysis and provide transparency to the public about the performance of the Medicare Advantage program, particularly Special Needs Plans, with respect to disparities. This should include review of: 

  • the value of the new benefit coverage flexibility (which allows coverage of benefits to help enrollees with health-related social needs or long-term care needs) in addressing disparities, 
  • quality measures that allow for comparison of performance of plans on reducing disparities, 
  • incentives for plans to test and evaluate programs to reduce disparities and improve equity, and 
  • reporting, using standardized data, on MA plan initiatives to improve health equity and reduce disparities. 

Enforcing standards

CMS should monitor the activities of all private health plans participating in Medicare to ensure compliance with all requirements. If CMS detects violations, the agency must enforce the requirements in a timely manner through the use of intermediate sanctions or contract termination, as appropriate.