Big Medicare insurers often deny requests for nursing-home stays

The Wall Street Journal – Thursday, June 11, 2026
By Anna Wilde Mathews

If you’re a senior, the Medicare plan you choose may have a major impact on whether you can get nursing-home care when you need it—and a new federal investigation shows the largest insurers had some of the highest denial rates.

Medicare insurers had widely varying rejection rates for patients seeking nursing-home stays, as well as for long-term care hospitals and inpatient rehabilitation facilities, according to two new reports from the Office of Inspector General for the Department of Health and Human Services.

The Medicare insurers with the biggest enrollments, UnitedHealth Group, CVS Health’s Aetna and Humana, were among the most likely to initially refuse access to the costly facilities.
Medicare insurers initially rejected a significant share of requests for nursing-home care
Medicare insurers by rate of denials

For these companies, denial rates hovered around 13% for nursing-home care, but they were far higher for patients trying to get into the other types of facilities. For long-term-care hospitals, initial rejection rates were as high as 80%.

The new investigation “raised concerns that some patients may have been denied medically necessary care,” said Rosemary Bartholomew, the lead author of the reports. Medicare typically covers a nursing-home stay if patients still need high-level, skilled care after a hospital admission of three days or more.

Insurers have long said that their preapproval requirements aim to ensure that patients don’t get unnecessary or harmful care.

For seniors enrolled in traditional Medicare, instead of private Medicare Advantage plans, there is generally no need to get the same kind of preapproval.

The Centers for Medicare and Medicaid Services said it was committed to protecting Medicare enrollees’ access to medically necessary care and ensuring insurers comply with coverage requirements.

CVS Health’s Aetna said that “when combined with timely clinical information from our provider partners, prior authorization supports safe, effective, and affordable care.” Other insurers had no immediate comment early Thursday morning.

The two new reports from the inspector general, which focused on data for June 2024 and included the 19 largest Medicare insurers, come while the industry is making public promises to cut back on and smooth prior authorizations for care, long a pain point for doctors and patients.

The inspector general also examined the role of contractors that insurers hire to review authorization requests. NaviHealth, owned by UnitedHealth and used by its insurance unit, had a relatively high denial rate of 14% for nursing-home care.

The investigators found that most people didn’t appeal when insurers denied their doctors’ request for access to a nursing home—specifically, a skilled nursing facility, the type of nursing-home care covered by Medicare. Bartholomew said that those who didn’t appeal may have gotten a different, lower-cost type of care, like home health, but the investigation didn’t focus on that.

Appealing does appear to pay off: Of the 18% of patients who did appeal, nearly all of them were able to overturn the initial denial of skilled nursing care.
Percentage of appeals that succeeded in overturning insurers’ initial nursing-home denials

Overall, there were far fewer requests for access to long-term care hospitals and inpatient rehab facilities, which are typically used for fragile patients who need even more high-level care than a nursing home can provide. Requests for these facilities were denied at far higher rates: 65% on average across all the insurers for long-term care hospitals, and 54% for inpatient rehab.

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