Full Breakdown
Medicare Advantage Plans Under Scrutiny for Post-Acute Care Denials
6/12/2026, 2:23:31 AM
Investigation Findings and Context
On June 11, 2026 the HHS Office of Inspector General issued two reports on Medicare Advantage (MA) plans’ prior-authorization practices for post-acute care. The analysis focused on UnitedHealth Group, Humana and CVS Health/Aetna, covering most of the 35 million MA enrollees. The reports found widespread denials of skilled-nursing, long-term acute-care and rehabilitation requests. The reports also flagged limited oversight of external contractors, such as NaviHealth, that process many prior-authorization decisions.
Key Statistics on Denials and Costs
Denial rates ranged from 13 % for skilled-nursing to 42-80 % for long-term acute-care; CVS Health/Aetna denied 80 %, Humana and UnitedHealth over 70 % (UnitedHealth 66 % for rehab). $49 k (long-term acute), $24 k (rehab), $16 k (skilled nursing), $6 k (home). Appeals reversed 36 % of long-term care, 43 % of rehab and 95 % of skilled-nursing denials.
Official Statements and Policy Moves
Rosemary Bartholomew said the 95 % overturn rate signals a breakdown at the initial request stage. Health Secretary Robert F. Kennedy Jr. announced commitments to streamline prior authorizations, citing industry pledges to cut 11 % of such requirements. Aetna highlighted a review and clear appeals process; UnitedHealth and Humana declined comment.
Industry and Advocacy Criticism
AHIP spokesperson Chris Bond argued the reports omitted “well-documented concerns” about cost and quality variation in post-acute care. LeadingAge vice president Nicole Fallon said families are “stressed” and unable to care for loved ones at home when insurers deny needed services. Analysts noted denial rates among profit-seeking plans.
Patient and Family Impact
Denied patients are often sent home early, facing out-of-pocket costs for home care or full-rate skilled-nursing. AARP reports a 50 % rise in home-care and assisted-living costs (2019-2024), outpacing senior income growth.
Conflicting Data and Gaps
The OIG reports show divergent figures: one analysis cites a 13 % denial rate for skilled-nursing requests, while another notes over half of long-term care or rehabilitation requests were rejected. The June 2024 data cover 19 plans but lack patient-outcome tracking and contractor criteria.
Verbatim Quotes
- “The dominance of a few large insurance companies in Medicare Advantage and the use of contractors to process prior authorization requests means that the policies and performance of just a few companies can impact care for millions of people,” — Rosemary Bartholomew, lead author, HHS Office of Inspector General
- “Imagine knowing you're not ready to go home, you can't go to the bathroom, you still need help but they're (insurance companies) saying no,” — Nicole Fallon, vice president, LeadingAge
- “These denial rates are quite staggering,” — Miranda Yaver, assistant professor of health policy and management, University of Pittsburgh
- “The range of denial rates from 8% all the way up to 80% by company for long-term care, that’s a pretty shocking variation,” — Erin Bliss, assistant inspector general, HHS
Outlook and Next Steps
CMS is urged to collect prior-authorization data and consider penalties for systematic wrongful denials. Lawmakers are drafting legislation to increase transparency of contractor criteria.
