The Centers for Medicare & Medicaid Services (CMS) on Nov. 26 issued the Contract Year (CY) 2026 Medicare Advantage (MA) and Medicare Prescription Drug Benefit Program (Part D) proposed rule. The proposed rule aims to increase transparency, equity, and patient access in the MA and Part D programs.
Coverage of Anti-Obesity Medication
CMS proposes to reinterpret statute to permit coverage of anti-obesity medications to treat obesity as a chronic condition. The proposed rule would no longer exclude anti-obesity medications from Part D or Medicaid when used to reduce excess body weight and maintain weight reduction long-term for individuals with obesity.
Prior Authorization and Utilization Management Safeguards
CMS proposes to build on the prior authorization and utilization management protections previously codified in the CY 2024 MA and Part D rule. Specifically, the proposed rule clarifies when and how MA organizations can use these tools by:
- Defining “internal coverage criteria” to mean any policies, measures, tools, or guidelines, whether developed by an MA organization or a third party, that are not expressly stated in applicable statutes, regulations, national or local coverage determinations, or CMS manuals, and are adopted or relied upon by an MA organization for purposes of making a medical necessity determination
- Adding rules for the publication of internal coverage criteria
- Clarifying processes on appeals, approved authorizations, and organization determinations
Guardrails for Artificial Intelligence (AI)
In a January 2024 request for information, CMS solicited comments on how MA plans use AI and AI’s potential impacts on health disparities. In this rule, CMS proposes to revise the MA regulations to ensure that services provided do not lead to inequitable treatment or prevent access to care. CMS may conduct program audits and/or take enforcement action when an MA organization fails to comply with the regulations.
Integrating Provider Directory Information into Medicare Plan Finder
CMS proposes to require MA organizations to submit provider directory information formatted to the agency’s specifications for use on Medicare Plan Finder (MPF) and to attest to data accuracy. This proposal aims to enhance MPF by making provider network information searchable for all MA organizations.
Ensuring Equitable Access to Behavioral Health Benefits
CMS proposes to limit cost sharing for behavioral health service categories for MA and Section 186 Cost Plans to be no greater than in traditional Medicare when services are provided in network.
Administration of Supplemental Benefits Coverage through Debit Cards
CMS proposes to clarify when and how MA organizations and enrollees may use debit cards, add disclosure requirements for debit cards, and require MA organizations to allow an enrollee to receive covered benefits through an alternative method if there is an issue using the debit card.
Improving Experiences for Dually Eligible Enrollees
CMS proposes to establish requirements for certain dual eligible special needs plans (D-SNPs) for integrated member identification cards and integrated health risk assessments (HRAs) for both Medicare and Medicaid. The agency also proposes to codify timeframes for all SNPs to conduct HRAs and individualized care plans (ICPs). Finally, CMS proposes to prioritize the involvement of the enrollee or the enrollee’s representative, as applicable, in ICP development.
Comments on the proposed rule are due Jan. 27, 2025.
Contact Director of Policy Rob Nelb, MPH, at rnelb@essentialhospitals.org or 202.585.0127 with questions.
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