2026 Policy for Medicare Advantage and Medicare Prescription Drug Benefit Programs and Other Programs

The Contract Year (CY) 2026 MA and Part D final rule implements changes related to prescription drug coverage, the Medicare Prescription Payment Plan, dual eligible special needs plans (D-SNPs), Star Ratings, and other programmatic areas, including the Medicare Drug Price Negotiation Program. The rule finalizes a provision that will restrict MA plans’ ability to reopen and modify a previously approved inpatient hospital decision, takes steps to close MA appeals loopholes, defines non-allowable Special Supplemental Benefits for the Chronically Ill (SSBCI), updates risk adjustment data requirements, and requires D-SNPs to have integrated member identification cards and conduct enrollee integrated health risk assessments beginning in 2027. Additionally, CMS is finalizing proposals to codify statutory requirements in the Inflation Reduction Act, including no cost sharing for adult vaccines and limiting the cost of insulin to $35. Additionally, the rule finalizes new requirements for an automatic election renewal process for the Medicare Prescription Payment Plan.

The final rule does not implement some provisions in the proposed rule, including coverage of anti-obesity medications, improved oversight of agent and brokers marketing materials, and new guardrails on MA use of artificial intelligence. The administration deferred finalizing several proposals until further rulemaking can occur, including additional plan directory requirements, star rating changes, and behavioral health cost-sharing.