Medicare Advantage

Medicare beneficiaries who enroll in a Medicare Advantage plan deserve the same access to high-quality, timely eye care they would receive in traditional Medicare. The Academy supports the role MA can play in coordinated, value-based care — but the program's rapid growth has not been matched by adequate guardrails for patients or physicians.

Inappropriate prior authorization requirements, step therapy protocols, automatic downcoding of evaluation and management visits, and aggressive medical-record requests add cost and delay to care that traditional Medicare would cover without question. These policies burden ophthalmology practices and, more importantly, delay medically necessary care for patients.

Championing federal prior authorization reform

The Academy helped craft and continues to push for passage of the Improving Seniors' Timely Access to Care Act (H.R. 3514/S. 1816), which would establish electronic prior authorization, real-time decisions for routinely approved services, firm response deadlines, and public reporting on MA plan utilization-management practices. Academy advocacy was instrumental in the bill's reintroduction in the current Congress.

Engaging CMS on MA regulations

The Academy submits detailed comments on CMS's proposed reforms to the MA program, urging stronger oversight of prior authorization, step therapy, medical-record requests, and network adequacy — and supporting provisions that align MA coverage with traditional Medicare.

Educating members on coding integrity

The Academy provides resources to help members recognize, document, and appeal automatic downcoding and inappropriate claim denials, and to understand the distinction between upcoding and downcoding under MA plan audits.

Direct payer engagement

Academy staff and physician leaders meet directly with major MA payers to address coverage and reimbursement policies that conflict with the standard of care for ophthalmic disease.

Tracking and member alerts 

Academy staff monitor published payer alerts, proposed and final policy changes, and member-reported claim issues. The Academy's Payer Issues Tracker provides up-to-date information on payer issues the Academy is actively working to resolve, with status updates and corresponding guidance on what members can do. 

Use the Academy's advocacy tools to urge your legislators to support the Improving Seniors' Timely Access to Care Act and other federal reforms to Medicare Advantage oversight.

Check the Payer Issues Tracker regularly for updates on MA plan policies affecting ophthalmology — and to report new issues your practice has encountered. Member reports help the Academy identify trends and prioritize engagement with payers and regulators.

If you experience MA-related claim denials, downcoding, or prior authorization delays that appear inconsistent with Medicare coverage standards, document the cases carefully and contact the Academy at healthpolicy@aao.org. 

Medicare Advantage is the private-plan alternative to traditional fee-for-service Medicare. Enrollees receive their Medicare Part A and Part B benefits — and usually Part D — through private insurers that contract with CMS.  

Enrollment in MA has grown dramatically. As of 2025, roughly 55 percent of Medicare-eligible beneficiaries were enrolled in an MA plan, up from about one-third a decade earlier. For ophthalmology, this growth has translated into more administrative work and delays to medically necessary care. Conditions such as wet age-related macular degeneration, diabetic retinopathy, and glaucoma require timely, individualized treatment — and delays caused by plan utilization-management practices can result in irreversible vision loss.