CMS issues CY 2026 MA and Part D final rule, rate announcement
CMS recently issued a final rule to detail policy and technical changes to Medicare Advantage (MA) and Part D programs for contract year (CY) 2026. The rule finalized proposals related to the MA appeals process, implementation of the Medicare Prescription Payment Plan program, and more.
CMS finalized several proposals aimed at closing loopholes in MA appeals processes that adversely affect providers and enrollees. The agency clarified that the definition of an “organization determination” includes an MA plan’s decision made concurrently with the enrollee’s receipt of services. Other steps taken include codifying existing guidance on provider and enrollee notifications, as well as modifying existing regulations to clarify enrollees’ liability.
CMS finalized its proposal to restrict MA plans’ ability to reopen and modify a previously approved inpatient hospital decision based on information gathered after the approval. Moving forward, these plans can only reopen an approved admission for obvious error or fraud, according to the agency.
The final rule codifies several Inflation Reduction Act (IRA) provisions, including certain vaccine and insulin cost-sharing requirements that were set to expire at the end of CY 2025. CMS finalized its proposal to codify parts one and two of final guidance released in 2025 for the Medicare Prescription Payment Plan, with minor modifications. The agency finalized a requirement for an automatic election renewal process that would continue a Part D enrollee’s participation in the program until they opt out.
The final rule also includes provisions related to special supplemental benefits for the chronically ill, risk adjustment data updates, dual eligible special needs plans, and more. Of note, CMS opted not to finalize the Biden administration’s proposals to expand Part D coverage of anti-obesity medications, require an annual health equity analysis of utilization management policies, and add new artificial intelligence guardrails in the MA program.
CMS also released the 2026 MA and Part D rate announcement to detail new MA payment factors and changes to the Part D benefit that reflect IRA provisions taking effect on January 1, 2026. The updates include the 2026 out-of-pocket threshold, liability changes related to the Medicare Drug Price Negotiation Program, and the establishment of the selected drug subsidy program.
These regulations take effect on June 3, and the final rule is expected to be published in the Federal Register on April 15. Revenue integrity professionals can read CMS’ fact sheets on the final rule, rate announcement, and redesign program instructions for more information.