The Contract Year 2026 Medicare Advantage (MA) and Part D proposed rule by the Centers for Medicare & Medicaid Services (CMS) aims to improve accountability, transparency, and access to high-quality healthcare. It introduces significant policy changes in areas like prior authorization, artificial intelligence (AI) guardrails, anti-obesity medication coverage, behavioral health access, and marketing regulations.
Key Proposals:
- Coverage of Anti-Obesity Medications: CMS proposes to reinterpret Medicare Part D and Medicaid regulations to allow coverage of anti-obesity drugs for individuals with obesity, aligning with changing medical consensus.
- Strengthening Prior Authorization & Utilization Management: The rule seeks to address excessive denials and ensure MA plans follow Traditional Medicare standards for coverage decisions. New transparency requirements will make utilization management policies publicly accessible.
- AI Guardrails in MA Plans: The proposal ensures AI-driven decisions do not introduce bias or inequities in healthcare access.
- Enhancing Medicare Plan Finder (MPF): MA organizations would be required to submit provider directories to CMS to improve searchability for enrollees.
- Improving Behavioral Health Access: MA and Section 1876 Cost Plans’ in-network cost-sharing will be limited to Traditional Medicare levels for mental health, substance abuse, and psychiatric services.
- Marketing & Broker Regulations: CMS plans to tighten oversight on misleading ads and require brokers to discuss Medicare Savings Programs & Low-Income Subsidies before enrollment.
- Supplemental Benefits via Debit Cards: Clearer rules on debit card usage for MA supplemental benefits, ensuring transparency and appropriate spending.
- Medicare Part D Prescription Payment Plan: CMS proposes automatic renewal for enrollees in the monthly payment program for prescription drug costs, beginning in 2026.
- Promoting Generic & Biosimilar Drug Use: New rules would ensure Part D formularies prioritize lower-cost generics and biosimilars over expensive brand-name drugs.
- Pharmacy Network Transparency: Plans must provide clear pharmacy participation details and allow pharmacies to terminate contracts with the same notice period as plans.
- Expanding Medication Therapy Management (MTM): CMS proposes including all dementias, not just Alzheimer’s disease, in MTM eligibility criteria.
- Community-Based Service Transparency: In-home and community-based service providers will be clearly identified in provider directories to ensure safety and informed choice.
These changes are aimed to enhance patient protections, increase transparency, and improve healthcare access while ensuring MA and Part D plans operate fairly and effectively. Read the complete overview from CMS at: