CMS issues 2026 MA and Part D proposed rule

CMS recently issued a proposed rule to spell out potential policy and technical changes to Medicare Advantage (MA) and Part D programs for 2026. The rule includes provisions aimed at expanding patients’ access to high-quality care, improving prior authorization processes, and more.

CMS is proposing to expand Part D coverage of anti-obesity medications. As of now, these drugs are only covered under Part D if they are used to treat another condition that is a medically accepted indication other than weight loss or management. The agency’s new proposal would permit coverage of these medications to treat obesity when such drugs are indicated to reduce excess body weight and maintain weight loss long-term for patients with obesity, according to the rule. However, this coverage would not extend to individuals who are overweight but do not have obesity.

To minimize inappropriate prior authorization and utilization management practices by MA plans, CMS is proposing to make the following adjustments to existing regulations:

• Clarify that if an enrollee has no further liability to pay for services furnished by an MA organization, the associated determination is not subject to CMS’ administrative appeal process
• Modify the definition of an organization determination to clarify that if an MA organization’s coverage decision is made when an enrollee is receiving such services, it would be considered an organization determination subject to appeal and other requirements
• Strengthen requirements to ensure providers who make standard or integrated organization determination requests receive proper notice of MA organizations’ decisions
• Change the reopening rules to eliminate an MA organization’s discretion to reopen approved authorizations for inpatient hospital admissions

The proposed rule also includes provisions aimed at limiting MA in-network cost-sharing for behavioral health services to be no greater than the traditional Medicare rates. For example, MA plans currently have a 50% coinsurance for opioid treatment program services, but CMS is proposing to change this to zero cost-sharing. The agency is soliciting comments on the potential transition period to implement these new behavioral health cost-sharing standards.

CMS is proposing to codify parts one and two of final guidance released earlier this year for the Medicare Prescription Payment Plan, as well as implement the requirements for 2026 and beyond. The agency is also proposing an automatic election renewal process that would continue a Part D enrollee’s participation in the program until they opt out.

The proposed rule also includes provisions on agent and broker requirements, artificial intelligence guardrails, medical loss ratio reporting, and more. Revenue integrity professionals can view CMS’ fact sheet and press release on the rule for more information.

The rule is scheduled to be published in the Federal Register on December 10. Comments are due no later than January 27. For tips on how to write and submit comments on proposed rules, see NAHRI’s white paper “Advocacy in Action: Commenting on Proposed Rules.”