Priority Issues Across Medicare, Part 2: Private Plans and Information Needs

The Medicare Rights Center’s work touches all aspects of the Medicare program, including Original Medicare (OM), private Medicare Advantage (MA) and Part D prescription drug plans, and supplemental coverage like Medigaps.

Our Focus

Our policy work centers beneficiaries and our commitment to the Medicare promise of guaranteed, high quality, and affordable coverage. We endeavor to safeguard Medicare’s foundational principles—universality, comprehensive benefits, and adaptability to beneficiaries’ diverse needs.

Our policy priorities are informed by the needs of Medicare beneficiaries. We learn of these needs through calls to our national helpline. For example, in our most recent helpline trends report, 41% of callers had questions about Medicare affordability and cost-assistance programs; 27% had access-to-care questions such as coverage, billing, or denials; 24% had questions about Medicare enrollment; and 8% were a mix of various issues. Importantly, most of these calls occurred before major prescription drug changes through the Inflation Reduction Act went into effect.

In Part 1, we focused on Original Medicare; now we turn our attention to other aspects of the program.

While some of these issues are common across all areas, including affordability, access to benefits, and care quality, others, like network adequacy, are concentrated in a subset of coverage options. In Part 1, we focused on OM; now we turn our attention to other aspects of the program.

Medicare Advantage

MA covers all of OM’s benefits and can also offer supplemental benefits. But enrollees may face issues with access to care due to lack of network providers, denials of care, and unexpected barriers to supplemental benefits.

We advocate that CMS use powerful oversight tools to ensure MA plans are providing the coverage they are paid to provide.

We will continue to advocate that the Centers for Medicare & Medicaid Services (CMS) use powerful oversight tools and data collection to ensure MA plans are providing the coverage they are paid to provide.

Supplemental Benefits

Some beneficiaries with limited incomes and resources may forgo OM’s free choice of providers to gain access to MA’s supplemental benefits. In some cases, these benefits are filling in gaps in OM’s coverage such as dental, vision, and hearing benefits. In others, they promise to help enrollees struggling with the costs of daily living to help make ends meet through cash-like benefits for food, over-the-counter products, help with rent or utilities, or coverage of a portion of the Part B premium. But hidden or complex eligibility rules and lack of data mean that some of these benefits may be more for show than true assistance. Improvements to Medicare Plan Finder have recently improved information about these benefits, but there is more work to be done. We will continue to urge greater oversight of beneficiary access to supplemental benefits, including ensuring the people get what they were promised.

Overpayment

MA plans are more expensive for beneficiaries and taxpayers than OM. In 2025, MA overpayments drove up Part B premiums by $212 per person, for a total of $13.4 billion.

Despite promises that MA would save Medicare money, it never has.

This is a long-standing issue. Despite promises that MA would save Medicare money, it never has. Since 2016, MA overpayments have added $82 billion to Part B premiums and hundreds of billions more to Medicare expenses.

Prior Authorization, Denials, and Appeals

Each year, the majority of questions we receive about coverage denials are related to MA. Callers are often struggling with what to do next, from trying to unpack confusing plan communications to navigating the complex MA appeals process. 

For all, coverage denials can be extremely stressful and disruptive, often forcing beneficiaries to choose between seeking other care, paying out of pocket, going without, or getting embroiled in a daunting appeals system. Too often, these denials are inappropriate. And even successful appeals come at a cost, including care delays and negative health outcomes. 

Even successful appeals come at a cost, including care delays and negative health outcomes.

Several studies, as well as our own experiences, indicate prior authorization can hinder access to care, and that improper plan decisions are prevalent: while few beneficiaries appeal, most who do are successful.

Network Adequacy

Medicare Rights’ helpline callers often report issues finding in-network providers, and they are not alone. A report from the Department of Health and Human Services watchdog Office of Inspector General (OIG) finds that MA directories, specifically for behavioral health providers, are wildly inaccurate and the underlying networks of these providers are inadequate to serve the needs of enrollees. “Ghost networks,” where plans hide the small number of in-network providers by including inactive providers, is a longstanding issue in MA. At Medicare Rights, we urge more oversight of networks, higher standards for network adequacy, and better directories with the information people need to make informed decisions.

Plan Selection and Proliferation

Having a large number of plans to choose from might sound ideal, but it leads to choice overload and keeps many beneficiaries from finding the best available fit. Medicare Rights urges policymakers to create better decision tools and standardized plans to help ensure people have the right information and only high-quality coverage options.

Part D

As with MA, private Part D plans can embroil enrollees in cycles of denials and appeals and may not be providing the value they should.

Drug Affordability

People with Medicare are uniquely impacted by high drug prices, partly due to utilization and health status. Over two-thirds of Medicare beneficiaries have multiple chronic conditions and Part D enrollees take four to five prescriptions per month, on average.

Part D enrollees take four to five prescriptions per month, on average.

The Inflation Reduction Act (IRA) has helped Medicare Part D enrollees gain access to important medications through a redesign of the Part D benefit—including an out-of-pocket cap—and other features like drug price negotiation and better access to insulin and vaccines. But more must be done to bring down drug prices to ensure older adults and people with disabilities can get the treatments they need while protecting their pocketbooks.

Medicare Rights supports expanding and deepening drug price negotiations and fixing broken incentives that drive high drug costs.

Utilization Management, Denials, and Appeals

The Medicare Part D appeals process is an essential safety valve, allowing access to needed prescription medications—such as those that are not on the plan’s formulary, or are subject to high cost sharing, when formulary or lower cost alternatives are not appropriate. However, Part D enrollees often struggle to successfully navigate this overly complex, multi-step process, and it can also prove burdensome for pharmacists, plans, and prescribing physicians.

The Part D appeals process can prove burdensome for pharmacists, plans, and prescribing physicians.

This can result in delayed access to needed prescriptions, abandonment of prescribed medications, reduced adherence to treatment protocols, worse health outcomes, and higher costs for the patient and the Medicare program.  

Formularies

Part D plan formularies often make accessing necessary prescriptions difficult or cost-prohibitive for enrollees, and can mask financial incentives. For example, the Government Accountability Office (GAO) recommended that CMS monitor the effects of rebates on Part D plan formularies because drug manufacturers give plans rebates in exchange for preferential placement of their medications on the Part D plan’s formulary, reducing plan costs but not beneficiary cost-sharing obligations for that drug. Biased or discriminatory formulary design can also be used to dissuade some potential enrollees from choosing given plans.

Better Information Is Key

One overarching beneficiary need is better access to vital information and assistance from independent sources with no financial incentive to steer people into or out of private coverage. Our National Helpline provides assistance with counseling and advocacy to help individuals, caregivers, and professionals navigate Medicare’s complexities.

One overarching beneficiary need is better access to vital information and assistance from independent sources with no financial incentive.

In addition, we value State Health Insurance Assistance Programs (SHIPs), which provide unbiased, one-on-one counseling in every state, and urge policymakers to increase funding for this resource.

CMS must also do better when it comes to laying out the pros and cons of OM versus MA and protecting people with Medicare from predatory, overly aggressive, or misleading plan marketing.

Our Mission

To gain our support, any reforms must uphold Medicare’s universality, protect current benefits, and ensure the program meets the evolving needs of diverse beneficiaries through high-quality, affordable care.