CMS proposed major reforms on Nov. 26 for the Medicare Advantage and Part D programs for contract year 2026, including changes to prior authorization and weight loss drug coverage.
The agency is also looking for feedback on how MA medical loss ratios are calculated in order to address concerns surrounding vertical integration across the industry.
10 key proposals:
1. Weight loss drug coverage: Part D plans and Medicaid programs could provide coverage of GLP-1s for obesity after previously being excluded (unless they were being used to treat conditions such as diabetes).
2. Tightened prior authorization rules: CMS is looking to "address concerns about the overuse of prior authorization" by introducing clearer definitions for internal coverage criteria, stricter transparency requirements for insurers, ensuring enrollees are informed about their appeal rights, and collecting more data on initial coverage decisions and appeals.
3. Medicare Shared Savings Program adjustments: CMS is proposing new standards for MA medical loss ratio reporting to better align with Medicaid and commercial requirements.
"In addition to the proposed changes, we are issuing a request for information on potential policies that CMS could adopt regarding how the MA and Part D MLRs are calculated in order to enable policymakers to address concerns surrounding vertical integration in MA and Part D."
4. Marketing: CMS is proposing to expand the definition of "marketing" to cover more materials and activities related to MA and Part D plans, requiring more advertisements and communications to be reviewed by the agency before being shared with the public. The new rule also focuses on improving consumer tools on Medicare.gov. Brokers must discuss additional topics, such as Medigap rights and low-income subsidy eligibility.
5. Artificial intelligence: CMS aims to enforce equitable access to care, regardless of delivery by humans or AI tools. MA plans using AI must comply with anti-discrimination laws and provide fair, unbiased access to services.
6. Medicare Plan Finder: MPF will include searchable provider directories for Medicare Advantage plans. MA organizations must update provider data within 30 days of changes and ensure accuracy through CMS compliance checks.
7. Supplemental benefits via debit cards: CMS is clarifying rules for using plan debit cards for supplemental benefits, requiring transparency and alternative processes for covered services. Plans cannot advertise supplemental benefit dollar values or debit card usage prominently.
8. D-SNP: These plans must use integrated ID cards for Medicare and Medicaid and conduct unified health risk assessments.
9. Behavioral: MA and Section 1876 Cost Plans must align behavioral health cost-sharing with traditional Medicare standards.
10. In-home care transparency: Plans must list in-home service providers in directories and specify those affiliated with community-based organizations.
Read the full proposed rule here.