David J. Meyers

With more than half of Medicare beneficiaries choosing to receive their coverage through private Medicare Advantage plans, more evidence is needed to understand Medicare Advantage enrollment of marginalized populations, including transgender beneficiaries. In this cross-sectional analysis of 60,797 transgender and 403,357 cisgender beneficiaries from 2012 to 2023, cisgender beneficiaries had a 3.14% higher probability of Medicare Advantage enrollment compared with transgender beneficiaries. In addition, we found significant variability in Medicare Advantage enrollment among transgender and cisgender beneficiaries by observed covariates (e.g., race, age, original reason for Medicare entitlement). Overall, there are differential trends in Medicare Advantage enrollment by gender identity and other characteristics, including race, ethnicity, age, and other demographics.

Objective: To compare the use of brokers in Medicare Advantage plans and standalone Part D plans. Study Setting and Design: We used plan‐level broker enrollment data from 2014 to 2023 to compare the rates of broker use in Medicare Advantage and standalone Part D plans. Data Sources and Analytic Sample: We used broker enrollment data obtained from the Centers for Medicare and Medicaid Services through a Freedom of Information Act request and data from the Medicare Master Beneficiary Summary File. Our sample included 47,862 plan‐years from 2014 to 2023. Principal Findings: In 2023, new enrollees in Medicare Advantage plans were more likely to be enrolled by a broker than those in standalone part D plans (35.6% compared to 27.1%). These results were generally consistent over time, within insurers, and across states. Conclusions: Broker use is more common in Medicare Advantage plans than in standalone Part D plans. Given that brokers are often paid more to enroll beneficiaries in Medicare Advantage plans than in standalone Part D plans, these results suggest that brokers may play a key role in driving Medicare Advantage enrollment growth.

Medicare Advantage (MA) plans increasingly outsource core functions to third-party vendors, a trend termed the “vendorification” of MA. Vendors now play major roles in star-rating maximization, risk-code capture, and prior authorization, with evidence that vendor-conducted prior authorization yields higher denial rates and more appeal reversals than reviews conducted internally by insurers. This commentary examines 3 potential challenges that may be posed by vendorification: increased federal spending through non–budget-neutral risk adjustment and quality bonuses, opportunities to game medical loss ratio requirements, and weakened accountability to beneficiaries' long-term health. Potential policy responses include mandatory reporting of vendor spending and, more fundamentally, reforming the payment incentives that make revenue-generating vendor services profitable.

We examined outpatient mental health counseling use among transgender and gender-diverse (TGD) and cisgender Medicare beneficiaries from 2011 to 2019 using a cross-sectional analysis of Medicare claims data. TGD individuals were identified using a validated claims-based algorithm. The sample included 39,215 TGD beneficiaries and a 20% random sample of cisgender beneficiaries ( N = 17,375,985). Similar to prior studies, TGD beneficiaries were more likely to use outpatient mental health counseling than cisgender beneficiaries. TGD beneficiaries were less likely to receive only one visit. TGD beneficiaries were also more likely to have visits with a licensed clinical social worker (LCSW), rather than a clinical psychologist. These findings highlight nuances in mental health counseling use among TGD Medicare beneficiaries and their differences relative to cisgender beneficiaries, including more intense utilization and a different provider specialty mix.

Background: Medicare‐funded home health care is providing critical care to homebound older adults, especially those in the last year of life. In Medicare Advantage, Hispanic and Asian or Pacific Islander decedents are less likely to receive Medicare home health compared to their counterparts in traditional Medicare. Methods: We aim to investigate if prior authorization contributes to racial and ethnic differences in Medicare home health use at the end of life. In this cross‐sectional study, we used a 100% Medicare cohort of adult's age ≥ 66 who died in 2019 and were enrolled in Medicare Advantage. We fit a logistic regression model with and without a Medicare Advantage plan‐level fixed effects and tested interactions between decedent race and ethnicity and whether the Medicare Advantage plan required prior authorization for Medicare home health care. All models adjusted for individual and regional characteristics. Results: In our sample of 369,195 decedents (49.3% female, mean age 84.9), 240,339, or 65.1%, were in Medicare Advantage plans that required prior authorization for home health care. Racial and ethnic differences were primarily driven by between‐plan differences, with prior authorization increasing differences in utilization between racial and ethnic groups. For example, prior authorization was associated with a 5.60% (95% CI 0.08–0.03) decrease for Hispanics and a 4.05% (95% CI 0.07–0.01) decrease for Asian/Pacific Islanders. Conclusion: Our findings suggest that prior authorizations contribute to racial and ethnic differences in the Medicare Advantage program.

Importance: Enrollment in Medicare Advantage (MA) plans continues to increase, now covering more than half of Medicare beneficiaries and receiving more than $494 billion in annual federal payment. Therefore, robust oversight is essential to monitor plans’ adherence to federal standards and initiate enforcement actions when necessary to ensure program integrity and protect beneficiaries. Objective: To examine Centers for Medicare & Medicaid Services (CMS) enforcement actions against MA contracts and characteristics of contracts and beneficiaries involved with enforcement actions. Design, Setting, and Participants: This is a cross-sectional study of CMS enforcement actions against MA contracts that were preferred provider organizations or health maintenance organizations from 2010 to 2023. Data were analyzed from May 2025 to January 2026. Exposures: Enforcement actions, including civil money penalties, suspension of enrollment, and contract termination. Main Outcomes and Measures: The outcomes of interest were number of enforcement actions and contracts affected and mean monetary penalties per MA enrollee. Results: There were 1173 unique MA contracts and 844 enforcement actions from 2010 to 2023. A total of 493 unique MA contracts (42.0%) received an enforcement action during the study period. Most of enforcement actions originated from program audit (544 actions [64.5%]). Enforcement activity varied widely across years: in 2012, 100 contracts (19.2%) received monetary penalties, while only 5 contracts (0.9%) received such penalties in 2019. Most enforcement actions were monetary penalties (737 actions [87.3%]), with far fewer enrollment suspensions (99 actions [11.7%]) and contract terminations (8 actions [0.9%]). Financial penalties peaked at $6.50 per enrollee in 2019 and remained less than $3 in other years. Compared with contracts that did not receive enforcement actions, contracts that were terminated had lower star ratings (mean [SD], 2.5 [0.5] stars vs 3.6 [0.6] stars) and enrolled a much lower share of White beneficiaries (44.7% vs 68.7%); suspended contracts enrolled more dually eligible beneficiaries (28.9% vs 18.8%). Conclusions and Relevance: This cross-sectional study found that federal enforcement actions against MA plans were highly variable from year-to-year and imposed modest fines. Enforcement actions may be relatively modest in magnitude, raising concerns about their effectiveness in deterring nonadherence. The design of oversight and enforcement actions warrant further evaluation to determine what amount of enforcement actions are needed to protect patients and ensure plans meet federal standards.

Introduction: Medicare Advantage plan payment depends on the health of enrolled patients. As a result, the extent to which beneficiary clinical severity is documented administratively—known as coding intensity—is greater in Medicare Advantage (MA) than in traditional Medicare, which inflates payment to plans. In 2024, the Centers for Medicare and Medicaid Services began phasing in a new risk adjustment model intended to reduce the susceptibility of MA payments to higher coding intensity. Methods: Using 2021 data, we compared average MA contract risk scores under the new model and the old model. Results: Risk scores were 5.8% lower under the new risk adjustment model. Differences between average risks scores under the new and old model varied substantially across contracts and insurers. For example, 1 large insurer's risk scores were essentially unchanged across models while another large insurer's risk score was 18% lower under the new model. Contracts with higher estimated coding intensity had greater exposure to the new risk adjustment model. Conclusion: Our results suggest that the new risk adjustment model will likely reduce MA payments due to enhanced coding intensity, with these reductions appropriately targeting insurers that code more intensely.

Health care consolidation continues to increase in the United States. Most of the evidence focuses on horizontal consolidation or vertical consolidation between hospitals and physician practices. The lack of comprehensive and longitudinal data identifying insurer and hospital vertical consolidation has limited study of the prevalence, variations, and impact of this form of consolidation. Therefore, we created a novel dataset of hospital-Medicare Advantage (MA) contract consolidation from 1980 to 2024. We illustrate the power of this novel dataset through analysis of annual trends in hospital-MA contract consolidation and state-level geographic variation in the share of hospitals consolidated with MA contracts. We also show that a quarter of hospital integrated MA contracts are owned by an MA insurer that owns other non-hospital integrated MA contracts. We make this dataset public to facilitate research on hospital-MA contract consolidation that can inform health care policy and anti-trust law.

Geronimo Bejarano, David J Meyers, Meredith B Rosenthal, Jeffrey Marr; Hospital-Medicare Advantage Vertical Integration and Medical Loss Ratios, Health Aff