Modernizing Medicare Advantage for the Next Generation of Seniors

When Medicare Advantage (MA) was created in 1997, it promised coordinated care and better value for seniors, with integrated care, prescription coverage and out-of-pocket protections absent in Original Medicare. 

Today, with 54% of seniors choosing MA, the program’s success is clear. But its future is at risk because of financial engineering by some and a disconnect between policy design and high-quality patient-centered care. 

At its core, the next phase of MA should align incentives around one goal: Ensure seniors can reliably access high-quality, affordable care without disruption, regardless of market dynamics.

The Centers for Medicare & Medicaid Services (CMS) took constructive steps in its 2027 final rule and rate announcement, particularly on payment integrity and quality measurement. But those steps are not the finish line. Policymakers should further modernize MA to strengthen competition, transparency and accountability. Here’s where to start:

Expand & measure supplemental benefits

MA’s supplemental benefits – from dental coverage to meal delivery – play a vital role in senior health. CMS has improved transparency, but policymakers should allow greater flexibility in structuring Special Supplemental Benefits for the Chronically Ill (SSBCI), including linking benefits to low-income subsidy status so services reach those in most need. CMS should also release public-use data files so stakeholders can better evaluate which benefits improve outcomes.  

Build on payment integrity progress

For 2027, CMS excluded “unlinked chart review” records from risk score calculations, a meaningful step toward strengthening payment integrity. 

The next step is aligning payment with clinical engagement, so diagnoses used for risk adjustment reflect actual care. A condition should drive care before it drives payment. CMS could require diagnoses to reflect meaningful encounters, such as face-to-face or telehealth visits, rather than retrospective documentation alone. 

A stronger step would be to leverage existing data and develop risk scores for individuals, rather than populations, improving accuracy and precision – a concept recently proposed by Abe Sutton and Gabriel Drapos.

Reduce prior authorization burden

Prior authorization remains frustrating for everyone. CMS should expand its efforts by requiring or piloting “gold carding” approaches – automatic approval for low-risk, low-variation services delivered by high-performing contracted providers. 

Alignment knows administrative burden can be reduced without compromising care. While large MA plans’ prior authorization denial rates range from roughly 4% to nearly 13%, ours is about half the lowest reported rate – and a fraction of the highest.

Promote access & affordability 

Today’s rules often measure access by signed contracts rather than actual access to care. Seniors’ choices are frequently constrained before they ever compare benefits because dominant hospital systems refuse to contract with smaller, high-performing MA plans, especially in rural and highly consolidated regions. In some markets, policy design favors large, vertically integrated systems.

Congress should address this imbalance by requiring hospitals that accept Original Medicare to also accept MA plans at Medicare rates unless a plan is under sanction. This “hospital parity” approach would expand access, strengthen competition and allow beneficiaries to choose plans based on value, not network exclusion.

Advance quality measurement & interoperability

In the 2027 final rule, CMS removed administrative, low-value measures and refocused Star Ratings on patient outcomes and experience. Yet, opaque cut-point mechanics still make performance difficult to interpret. CMS should adopt stable, transparent benchmarks that reward sustained improvement.

The system also continues to rely on fragmented, delayed information. Plans and clinicians often learn about hospitalizations too late to intervene. CMS should accelerate real-time data exchange by advancing interoperability standards, including APIs, electronic prior authorization and standardized data sharing. Better information should support proactive care, reduce administrative burden and improve outcomes.

Empower dual-eligible members with choice

Coordinated care should not come at the expense of choice and competition. In some states, policies like Exclusively Aligned Enrollment limit choice by requiring common ownership of MA plans and Medicaid managed care organizations, potentially forcing beneficiaries who are dually eligible for Medicare and Medicaid into lower-quality plans with narrower networks and less expertise in managing senior populations. 

Policymakers should preserve integration while allowing high-performing plans to compete, including pathways to participate in Medicaid without requiring full Medicaid integration. 

Protect seniors with transparent, accountable marketing

CMS’s 2027 policies maintain protections against misleading marketing while allowing greater flexibility for plans to communicate with beneficiaries. The focus should now be on enforcement.  

Bad actors – including agents and third-party marketing organizations engaging in deceptive or unauthorized enrollment practices – undermine trust. CMS should strengthen accountability through greater transparency in compensation, stronger oversight and more meaningful consequences, including barring agents terminated by one plan from all affiliated plans. Seniors deserve clear, accurate information when choosing coverage.

The way forward

MA has transformed care for millions of seniors, offering coordinated services, supplemental benefits and financial protection that Original Medicare does not. 

CMS’s recent actions represent progress. What comes next should reinforce what works and correct what doesn’t, allowing MA to remain a high-performing, patient-centered and fiscally responsible option for generations to come.

Photo: designer491, Getty Images

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