As we approach 2026, significant changes are on the horizon for Medicare Advantage (MA) plans.
The Centers for Medicare & Medicaid Services (CMS) has proposed several policy and technical adjustments to enhance beneficiary protections, expand access to care, and ensure the delivery of high-quality services. Here’s an overview of the key changes to anticipate.
Coverage of Anti-Obesity Medications
Recognizing obesity as a chronic disease, CMS proposes to reinterpret existing statutes to allow Medicare Part D to cover anti-obesity medications when prescribed for weight reduction and long-term maintenance in individuals with obesity.
This shift aligns with current medical consensus and aims to improve health outcomes for millions of Americans.
However, such medications would remain excluded from coverage when used by individuals who are overweight but do not have obesity or another medically accepted indication.
See also: Unlocking the Benefits of Cannazym: Solution for Healthier Plants
Strengthening Prior Authorization and Utilization Management
CMS has expressed concerns about barriers to care resulting from inappropriate prior authorization and utilization management practices within Medicare Advantage plans 2026.
To address these issues, the proposed rule seeks to:
- Clarify Internal Coverage Criteria: Ensure that MA plans’ internal coverage policies are transparent and publicly accessible.
- Establish Guardrails for Artificial Intelligence (AI) Use: Implement safeguards to prevent AI-driven decisions from leading to inequitable treatment or access to services.
- Enhance Oversight: Increase CMS’s ability to monitor and regulate prior authorization practices to ensure timely and necessary access to care.
Enhancements to Behavioral Health Access
To improve access to behavioral health services, CMS proposes that in-network cost-sharing under MA plans should not exceed the cost-sharing amounts in Traditional Medicare. This change aims to reduce financial barriers and encourage beneficiaries to seek mental health care.
Improved Transparency in Provider Directories
CMS plans to require MA organizations to make their entire provider directories available to CMS for integration into the Medicare Plan Finder tool. This initiative will enable beneficiaries to search for providers more easily and compare their availability across different MA plans, facilitating more informed decision-making.
Marketing and Communications Oversight
CMS intends to expand its oversight of MA advertisements to protect beneficiaries from misleading information. This includes:
- Broadening the Definition of Marketing: Increasing the number and types of advertisements plans must submit to CMS for review before use.
- Enhancing Agent and Broker Requirements: Requiring agents and brokers to provide potential enrollees with comprehensive information, including subsidy eligibility and the impact of MA enrollment on future Medigap rights.
Updates to Medical Loss Ratio (MLR) Reporting
CMS proposes revisions to MLR regulations to improve data reporting by MA and Part D plans. These updates aim to:
- Align with Commercial and Medicaid Standards: Ensure consistency across different insurance markets.
- Enhance Oversight: Provide CMS with better insights into how plans allocate funds, particularly concerning administrative costs and quality-improving activities.
Integration for Dually Eligible Beneficiaries
For beneficiaries eligible for both Medicare and Medicaid, CMS plans to establish new federal requirements for certain Dual Eligible Special Needs Plans (D-SNPs), including:
- Integrated Member Identification Cards: Serving as ID cards for both Medicare and Medicaid plans.
- Unified Health Risk Assessments: Conducting integrated assessments to streamline care coordination.
These proposed changes reflect CMS’s commitment to enhancing the Medicare Advantage program, ensuring that it meets the evolving needs of beneficiaries by promoting transparency, accountability, and access to high-quality care.
