CY 2026 Medicare Advantage and Part D Final Rule

somarco

GA Medicare Expert
5000 Post Club
38,241
Atlanta
CMS finalized a proposal to codify a relatively modest expansion of the definition of a "covered insulin product" to include Part D coverage for drug products that are a combination of more than one type of insulin or both insulin and non-insulin drugs,

MA organizations may not retroactively deny or downgrade previously authorized inpatient admissions, even based on clinical data collected after admission. The only exceptions are fraud or qualifying good cause.

Approved services, including inpatient admissions, cannot be retroactively denied unless there is evidence of fraud or a valid reason under CMS's "good cause" standard as defined in 42 CFR § 405.986.

In the Final Rule, CMS adopts a non-exhaustive list of non-primarily health related items or services that do not meet the standard of having a reasonable expectation of improving or maintaining the health or overall function of the enrollee. As finalized at 42 C.F.R. § 422.102(f)(1)(iii), examples of items or services that may not be offered as SSBCI include all of the following:

Procedures that are solely cosmetic in nature and do not extend upon Traditional Medicare coverage (for example, cosmetic surgery, such as facelifts, or cosmetic treatments for facial lines, atrophy of collagen and fat, and bone loss due to aging)

Hospital indemnity insurance

Funeral planning and expenses

Broad membership programs inclusive of multiple unrelated services and discounts


Perhaps most notable from the CY 2026 Final Rule are those proposals that CMS did not finalize.

CMS declined to finalize a proposal to "reinterpret" the statutory definition of a covered Part D drug at section 1860D–2(e)(2) of the Social Security Act (SSA), which excludes coverage for certain drugs and uses, including those that may be excluded by Medicaid under SSA § 1927(d)(2) as ''agents when used for . . . weight loss.''

While CMS finalized prior authorization requirements applicable to inpatient admissions (discussed below), CMS did not finalize proposals to establish guardrails on the use of AI in prior authorization processes.

MS did not finalize key proposed marketing reforms. Among other things, these included broadening the definition of "marketing" to enhance agency oversight of materials submitted to CMS as well as promoting informed choice by requiring agents and brokers to provide more comprehensive information to potential enrollees, such as low-income assistance options and implications of switching to traditional Medicare.


 
Back
Top