CMS Proposes Changes for 2026
Key Impacts of CMS’s 2026 Medicare and Medicaid Proposal
On December 10, 2024, the Centers for Medicare & Medicaid Services (CMS) published a proposed rule introducing significant policy and technical changes to the Medicare Advantage (MA) Program, Medicare Prescription Drug Benefit Program (Part D), Medicare Cost Plan Program, and Programs of All-Inclusive Care for the Elderly (PACE) for Contract Year 2026.
These changes aim to enhance beneficiary access to care, improve program integrity, and address evolving healthcare needs.
The following is a summary of some of the impactful changes. Please review the original document for detailed information.
Key Proposed Changes:
- Coverage of Anti-Obesity Medications (AOMs):
- Medicare Part D: CMS proposes to reinterpret existing statutes to allow coverage of anti-obesity medications under Part D, recognizing obesity as a disease and facilitating access to treatments that can improve health outcomes. CMS
- Medicaid Programs: The rule would require state Medicaid programs to cover anti-obesity medications, ensuring broader access across different populations. HHS
- Prior Authorization and Utilization Management Enhancements:
- Internal Coverage Criteria: The proposal seeks to clarify requirements for MA plans’ use of internal coverage criteria, ensuring that such criteria are transparent and do not create unnecessary barriers to care. CMS
- Artificial Intelligence (AI) Guardrails: CMS aims to establish safeguards around the use of AI in utilization management to protect beneficiary access to necessary health services. HHS
- Medical Loss Ratio (MLR) Reporting:
- Enhanced Data Reporting: The proposed rule would update MLR regulations to improve the data reported by MA organizations and Part D sponsors, promoting greater transparency and accountability in how funds are utilized. HHS
- Marketing and Communications Oversight:
- Strengthened Consumer Protections: CMS plans to expand oversight of MA and Part D advertisements to prevent misleading marketing practices, building on previous efforts to protect beneficiaries from predatory behaviors. HHS
- Network Adequacy and Access Improvements:
- Provider Directory Integration: The rule proposes that MA organizations make their entire provider directories available to CMS for incorporation into the Medicare Plan Finder, enhancing beneficiaries’ ability to compare provider availability across plans. HHS
- Star Ratings and Quality Measures:
- Measure Updates: CMS intends to add, update, and remove certain measures within the Star Ratings program to better reflect plan performance and beneficiary outcomes. Public Inspection Federal Register
Implications for Healthcare Payers and Providers:
These proposed changes underscore CMS’s commitment to improving access to care, ensuring program integrity, and enhancing beneficiary protections.
Healthcare payers and providers should prepare for adjustments in coverage policies, particularly concerning anti-obesity medications, and anticipate increased scrutiny regarding utilization management practices and marketing activities.
There is an opportunity to submit comments for consideration on the rule with a deadline for submission of January, 27th, 2025.
Public Comment Process
To engage in the public comment process before the January 27, 2025 deadline, leaders can follow these steps:
- Review the Proposed Rule: Thoroughly read the details of the proposed changes published in the Federal Register to understand the potential implications for your organization. Access the rule here.
- Identify Key Stakeholders: Convene a team of internal experts and decision-makers to analyze the proposed rule, focusing on its impact on your operations, compliance, and beneficiaries.
- Draft Comments: Prepare detailed, constructive feedback that highlights specific aspects of the proposed changes, providing data or case studies to support your position.
- Submit Feedback: Use the Federal eRulemaking Portal to submit your comments electronically. Include the docket number of the proposed rule (2024-27939) in your submission. Note: There are additional avenues for submission provided in the official document.
- Collaborate and Advocate: Work with industry associations or advocacy groups to amplify your concerns and recommendations.
References
Centers for Medicare & Medicaid Services. (2024, December 10). Medicare and Medicaid programs; Contract year 2026 policy and technical changes to the Medicare Advantage program, Medicare prescription drug benefit program, and others. Federal Register. Retrieved from https://www.federalregister.gov/documents/2024/12/10/2024-27939/medicare-and-medicaid-programs-contract-year-2026-policy-and-technical-changes-to-the-medicare
Centers for Medicare & Medicaid Services. (2024, November 26). Contract year 2026 policy and technical changes to Medicare Advantage program, Medicare prescription drug benefit program, and others. CMS.gov. Retrieved from https://www.cms.gov/newsroom/fact-sheets/contract-year-2026-policy-and-technical-changes-medicare-advantage-program-medicare-prescription
U.S. Department of Health & Human Services. (2024, November 26). Biden-Harris Administration announces Medicare Advantage and Medicare Part D prescription drug proposals. HHS.gov. Retrieved from https://www.hhs.gov/about/news/2024/11/26/biden-harris-administration-announces-medicare-advantage-medicare-part-d-prescription-drug-proposals.html
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