Medicare Advantage Enrollment Tops 54% – Why Health Plan Resilience Matters on the Path to 64%
According to Kaiser Family Foundation (KFF), 54% of eligible Medicare beneficiaries are now enrolled in Medicare Advantage (MA) plans. That’s up from just 19% in 2007, reflecting how quickly MA has grown from alternative coverage to mainstream. Yet at the same time, headlines show some plans exiting the MA and Part D markets. For payers, the question isn’t just how to handle growth — it’s how to stay resilient in the face of both expansion and contraction. This steady enrollment growth combined with plan exits represents a major opportunity for payers—but it also creates operational pressure. As membership grows, so do claims, time-sensitive CMS compliance requirements, and administrative costs, putting extra pressure on healthcare operations.
In this blog, we’ll explore:
Why Medicare Advantage growth brings new levels of operational complexity
The three biggest pressure points health plans must address
How organizations can prepare their infrastructure to scale efficiently and stay compliant
Rising Complexity Across Medicare Advantage Operations
The rise in Medicare Advantage enrollment is not just about scale; it fundamentally reshapes payer operations.
Enrollment applications must be processed accurately and on time to activate members and ensure downstream claims are valid
Claims operations face higher volumes and rising audit scrutiny
CMS compliance obligations are intensifying across marketing and member communications
Administrative workflows and legacy processes are under pressure as membership scales
Market exits add uncertainty, pushing payers to focus on resilience as much as scale
What happens when plans leave? In 2025 alone, more than 1.4 million MA-PD members were forced to seek new coverage due to full plan terminations—an increase of over 100% from 2024. Some national carriers terminated multiple plans across dozens of counties, requiring those members to shop again.
This isn’t just churn; it’s a redistribution shock. Remaining plans must absorb those members mid-cycle or during annual enrollment, further taxing claims, communications, and admin systems. Resilience, in this context, means being able to flex—not just grow—without breaking.
For many payers, these challenges compound, creating risk of delays, errors, and penalties if not addressed.
Top 3 Critical Resilience Tests for Health Plans
Accuracy Under Audit Pressure
Resilience in claims operations means withstanding both higher volumes and heightened scrutiny. As Medicare Advantage enrollment grows, the number of claims submitted by enrollees increases proportionally. But this isn’t just a throughput challenge; each claim carries coding and documentation requirements that feed into risk adjustment and revenue. With CMS now expanding RADV audits to all MA plans, even small inaccuracies can trigger financial clawbacks, audit findings, or penalties. Specialty populations also add complexity—for example, according to KFF, 21% of MA enrollees are in SNP plans, which can require additional eligibility verification with Medicaid or clinical criteria. For payers, the real challenge is building claims operations that are both fast and audit-ready.Communications Under Tightened Oversight
Resilient plans can keep member trust even under tighter oversight and higher volumes. Every new MA member generates a steady flow of regulated communications: Explanations of Benefits, ANOCs, denial notices, and appeals correspondence. CMS rulemaking now in effect — including the Contract Year 2024 Final Rule — tightened oversight of marketing and member notices to curb misleading practices and improve protections. That means delays or errors aren’t just costly; they can damage Star Ratings, invite regulatory scrutiny, and erode member trust. As enrollment grows, the communications burden scales just as quickly. For plans exiting markets, resilience means communicating clearly to minimize member disruption and confusion.Scaling Sustainably Under Margin Pressure
Resilience also means absorbing new members without breaking budgets. Medicare Advantage plans already operate with significantly higher administrative overhead than traditional Medicare, and growth in enrollment magnifies the operational pressure. Departures by some regional and national plans highlight how unsustainable costs and margin pressures are forcing tough decisions. Health plans face the dilemma of how to absorb more members without inflating overhead. Legacy intake methods don’t scale: manual work slows processing, errors multiply, costs rise, and backlogs build—turning simple workflows into bottlenecks. The organizations that succeed will be those that invest in automation, outsourcing, and integrated platforms to expand capacity without ballooning costs.
Path Forward: Building Scalable Infrastructure
The 54% Medicare Advantage enrollment milestone is more than just a statistic: it signals that Medicare Advantage is now the mainstream model, and payers who fail to modernize could fall behind. Growth will strain infrastructure unless organizations prepare now. And with projections indicating MA enrollment could rise to 64% in the next 10 years, the pressure will only intensify.
While hitting 54% is a benchmark, the real work is on the path to 64%—and the operations it will demand. But scale alone isn’t the story. With slower growth rates and plan exits making headlines, resilience is now as important as growth. The path to 64% will favor payers that can absorb shocks while keeping operations efficient and compliant. Building resilience isn’t about eliminating pressure; it’s about designing operations that can bend without breaking. The payers that thrive in this new Medicare Advantage environment will be those that invest in:
Automation – Reducing manual intervention across claims processing and member communications. Intake modernization, where legacy processes remain, further reduces downstream risk.
Integration – Breaking down silos so data flows seamlessly across workflows.
Scalability – Expanding operational capacity through smart technology and selective claims processing outsourcing, without expanding administrative overhead.
Ultimately, scaling successfully is not just about adding more tools or people—it requires building an operational foundation that can adapt quickly, absorb future growth, and stay compliant under expanding CMS oversight.
Preparing for the Future of Medicare Advantage
The uptick in Medicare Advantage enrollment signals a fundamental shift in the scale and complexity of payer operations. Claims operations, compliance obligations, and member communication processes that were once manageable are now becoming critical pressure points as volumes rise and compliance expectations tighten. The reality is mixed: growth continues, but not without turbulence. Some plans are recalibrating or exiting altogether, underscoring the need for resilience in addition to scale.
For health plans, the takeaway is clear: relying on legacy systems or manual processes is no longer sustainable. Meeting the demands of Medicare Advantage growth requires infrastructure that is faster, more accurate, and resilient enough to withstand regulatory scrutiny. Growth will continue, and exits will continue — resilience is what allows payers to navigate both.
Scaling healthcare operations doesn’t have to mean more strain. That’s where Imagenet comes in. We help more than 150 health plans reduce operational pressure through scalable automation, intelligent workflows, and compliance-driven solutions—enabling payers to handle today’s demands while preparing for tomorrow’s growth. Waiting until operational bottlenecks slow you down is no longer an option. Modernizing your processes now ensures your infrastructure can keep pace with rising claims, regulatory oversight, and evolving member expectations.
Don’t wait until compliance penalties or market pressures force tough choices. Imagenet helps health plans eliminate bottlenecks, reduce regulatory risk, and stay resilient as Medicare Advantage evolves.