What’s happening: In its finalized changes to the Medicare Advantage (MA) and Part D prescription drug programs for contract year 2026, the Centers for Medicare & Medicaid Services (CMS) struck most of the Biden-era proposals and declined to finalize additional insurer accountability provisions.
What else to know: The rule, which did not address several other proposals (detailed below), is effective Jan. 1, 2026.
CHA-supported proposals that were not addressed in final rulemaking:
- Fortifying requirements for MA plan use of internal coverage criteria
- Applying new guardrails for insurer use of artificial intelligence in claims processing
- Strengthening MA plan medical loss ratio reporting requirements
- Strengthening MA plan provider directory requirements
- Increasing oversight of agent and broker marketing activity
- Increasing oversight of supplemental benefits
- Limiting enrollee cost sharing for behavioral health services
- Requiring health equity analysis of utilization management requirements
CMS also declined to finalize a proposal that would have permitted the Medicare and Medicaid programs to cover weight loss medications.
However, the rule finalizes several helpful provisions for hospitals and health systems including:
- Strengthening MA enrollee rights to appeal MA coverage denials and supporting providers’ ability to appeal on a patient’s behalf
- Fortifying existing regulations that prevent MA plans from retrospectively denying previously approved services, including restricting MA plans’ ability to use information gathered after an inpatient admission when reviewing the appropriateness of the admission itself
The rule also finalizes proposals regarding vaccine and insulin cost-sharing for Part D plans; codifies requirements designed to improve enrollee experience in dual eligible special needs plans; and requires all Part D plans to require network pharmacies to be enrolled in the Medicare Drug Price Negotiation Program’s Medicare Transaction Facilitator Data Module.
Additional details are available in a CMS fact sheet.
Michelle Millerick
Patricia Blaisdell
