CMS releases proposed rule for 2026 Medicare Advantage, prescription drug plans
The Centers for Medicare & Medicaid Services Nov. 26 proposed changes to the Medicare Advantage and prescription drug programs for contract year 2026. Those changes would permit coverage of anti-obesity medications in the Medicare and Medicaid programs; fortify existing limitations on insurer use of internal coverage criteria and requirements for MA plans to provide coverage for all reasonable and necessary Medicare Part A and B benefits; and apply additional guardrails to insurer use of artificial intelligence to ensure it does not result in inequitable treatment or access to care. CMS also proposes to update MA and Part D plan medical loss ratio reporting requirements to improve oversight, align reporting with commercial and Medicaid reporting, and request additional information on MLR and vertical integration.
Among other provisions, the proposed rule would require MA plans to make provider directory information more widely available through the Medicare Plan Finder tool; limit enrollee cost sharing for behavioral health services to an amount that is no greater than Traditional Medicare; enhance CMS oversight of MA agent and broker marketing and communication materials; increase insurer reporting requirements related to insurer use of prior authorization and potential health equity implications; and add new requirements governing MA plan use of debit cards to administer enrollee supplemental benefits. Finally, the proposed rule would also codify several provisions in the Inflation Reduction Act, such as capping certain out-of-pocket costs in Medicare Part D, and other pharmacy-related provisions, such as new requirements for Part D sponsors on formulary inclusion and placement of generic drugs and biosimilars.
In a statement shared with media, AHA Senior Vice President Ashley Thompson said, “The AHA commends CMS for taking important steps to increase oversight of 2026 Medicare Advantage plans to help ensure enrollees have equal access to medically necessary health care services. The AHA has previously raised concerns about the negative effects of certain Medicare Advantage practices and policies that have the potential to directly harm patients through unnecessary care delays or outright denial of covered services.
“We appreciate that CMS’ proposed rule builds upon prior rulemaking to strengthen limitations on commercial insurer use of internal or proprietary coverage criteria that are more restrictive than Traditional Medicare and can compromise enrollee access to Medicare-covered services. We also are pleased that it would increase oversight of prior authorization and utilization management tools, apply important guardrails on insurer use of artificial intelligence, and update medical loss ratio reporting requirements to ensure appropriate oversight of vertically integrated insurers. As enrollment in Medicare Advantage has for the first time reached more than half of all people enrolled in Medicare, it is more important than ever to establish and implement stronger consumer and beneficiary protections and curtail practices that can impede patient access to care.
“The AHA will continue to carefully review the proposed rule and support efforts to improve the Medicare Advantage program for patients and their providers.”
For more on the rule, see the CMS fact sheet. AHA members will receive a Special Bulletin with further details about the proposed rule. Comments on the proposed rule are due Jan. 27, 2025.