Medicare Advantage (MA) continues to grow in enrollment, but understanding how coverage decisions are made – and what CMS requires – remains complex. In 2025, CMS tightened rules around prior authorization, clarified when plans can apply internal coverage criteria, and advanced transparency measures that will affect plan operations and provider interactions. These changes have significant implications for Medicare beneficiaries enrolled in MA plans and healthcare stakeholders navigating MA plans’ coverage and payment processes.
This +Insight explains what MA plans must cover, how coverage determinations work, and what recent regulatory actions mean for your organization. Read on to understand the evolving landscape and prepare for what’s ahead.
