Medicare Advantage · the payer behind the care

The web around a home doesn't stop at who owns it.

It runs to who pays for the care, and who says no to it. Most residents are on a Medicare Advantage plan now, and the plan decides, in advance, what care the home is allowed to deliver. A denied prior authorization is a real event in a resident's care: the skilled day, or the therapy, that didn't happen. So when you're building the picture at a specific institution, the payer belongs in it, right beside the owners and the management company. We've assembled the denial record across the six largest Medicare Advantage insurers, so that piece isn't a blind spot at your facility.

The denials aren't level. They're a 2× spread.

Across the six largest Medicare Advantage insurers' CY2025 disclosures, the standard-request denial rate runs from roughly 6.9% to 13.5%, about double, from one big plan to the next. The plan your client is enrolled in matters more than any national average suggests.

Counts published · volume-weighted denial ratethese four publish request counts
  • UnitedHealthcare13.5%
  • Centene / Wellcare13.3%
  • Kaiser Permanente10.1%
  • Humana6.9%
Percentages only · median contractcannot be volume-weighted
  • Aetna7.8%
  • Elevance / Anthem4.6%

CY2025, standard requests. Four insurers publish request counts, so their rate is volume-weighted; two publish percentages only, so we report the median contract and flag it rather than blend two things that aren't comparable.

When a denial is appealed, plans overturn most of them (the HHS Office of Inspector General found Medicare Advantage organizations overturned about 81% of appealed prior-authorization denials), yet almost no one appeals. Most denials simply stand.

There is no central source. So we built one.

We swept the federal open-data catalog and found zero matching datasets. CMS-0057-F requires the disclosure but sets no format and no repository. Each insurer posts one or more files on its own site, refreshed every March 31. Assembling it means handling six different shapes: a single consolidated UnitedHealthcare PDF, per-contract Humana files, Kaiser's full-precision XML, Aetna's one percentages-only PDF, Elevance scattered across brand sites, Centene across Wellcare and its brands.

  • UnitedHealthcareone consolidated PDF · uhc.com
  • Humanaper-contract files · humana.com
  • Kaiser Permanenteper-region XML · kaiserpermanente.org
  • Aetnaone metrics PDF (percentages only) · aetna.com
  • Elevance / Anthemper-brand PDFs + HTML · anthem.com and brand sites
  • Centene / Wellcareper-brand files · wellcare.com and brand sites

Every figure on this page traces to the insurer's own published file. None of these are our numbers. They are the insurers', assembled and dated.

Why the naive comparison is wrong.

The disclosures don't line up. Some report "denied and upheld" as a share of all requests; others as a share of appeals only; some omit it. Appeal denominators are frequently unpublished. One insurer's totals double-count if you sum them. Low-volume and delegated-utilization contracts can fake an artificially low denial rate. One insurer's file even mislabels an empty section with another company's contract number. We catch these before they become a headline, the difference between a number and a number that holds up.

Why this reaches the nursing-home case.

Medicare Advantage treats skilled nursing differently than traditional Medicare: it pays skilled-nursing facilities materially less, it runs far more prior authorizations, and (the finding that carries the most caveats) its enrollees are 2.5 to 4.2 percentage points less likely to enter a top-rated (4- or 5-star) home.

That last point is a facility-rating gap, not proven patient harm, and higher-rated plans roughly halve it. We say so plainly. These are payment-and-rating patterns drawn from public data, not a claim about any individual plan's or facility's conduct. What the denial data adds is the per-plan number behind the pattern.

The rule opens the directory. Most of it stays closed to the public.

Federal rule 42 CFR §422.120 (the provider-directory-API requirement CMS put in place in its 2020 Interoperability and Patient Access rule, in force since January 1, 2021) requires every Medicare Advantage organization to keep a directory API that anyone can reach: publicly accessible, no user authentication, no login, no fee, no account, at a public-facing endpoint on the plan's website. (The same interoperability program later produced CMS-0057-F, the 2024 rule behind the prior-auth numbers above.) So we probed them, organization by organization. On a single day in July 2026, only about a third of Medicare Advantage enrollment sat behind a directory API that answered a public request and returned the data the rule describes, five years after it took effect, and the requirement still stands unamended, with no enforcement relief and no court challenge.

Every plan owes all three. All six publish their denial numbers. Only UnitedHealthcare also opens its directory.
PRIOR-AUTH TRANSPARENCY all six publish the denial numbers PROVIDER-DIRECTORY API a public, open directory PATIENT / PROVIDER ACCESS share the record via API not publicly probed THE RULE interoperability mandate UnitedHealthcare 9.22M · public · compliant Humana 7.10M · public · incomplete Aetna · CVS Health 4.09M · login required Kaiser Permanente 2.05M · not published Elevance · Anthem 1.87M · blocked Centene · Wellcare 0.91M · blocked
  • 31.8%  publicly accessible and returns the required data · 12.2M enrollees
  • 24.1%  public, but missing required data or needs a key · 9.3M
  • 27.3%  behind a login or registration · 10.5M
  • 15.8%  blocked outright or never published · 6.1M

More than two-thirds of Medicare Advantage enrollment, then, is not behind the open, complete directory the rule describes. We report what a public probe found, on a date. Whether any single implementation counts as noncompliance is a legal judgment we do not make. But the pattern is the point: the same organizations deciding your client's care are, in most cases, not offering the access the rule calls for.

This is one of the many examples we showcase to you, beyond what other firms have as part of the lexicon of records for a given workup.

The nursing-home record is public and central. This is not, and that is the point. When the facts that matter live in six places, in six formats, refreshed once a year, the firm that has them assembled holds an edge the firm reading the public record alone does not. That is the work: we go where the facts are, not just where they're easy.

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Sources: CMS-0057-F payer prior-authorization disclosures (CY2025, each insurer's website); U.S. HHS Office of Inspector General reports on Medicare Advantage prior-authorization denials and appeal outcomes; KFF analysis of Medicare Advantage enrollment. Directory-API access: 42 CFR §§422.119–422.120 (publicly-accessible provider-directory API and documentation), with access status observed by public probe (July 2026) against CMS CPSC contract enrollment. Denial rates are each insurer's own published figures, as of the CY2025 disclosures (refreshed annually by March 31).