On April 4, the Centers for Medicare & Medicaid Services released a final rule updating the Medicare Advantage (MA) Program, Medicare Prescription Drug Benefit Program (Part D), Medicare Cost Plan Program, Programs of All-Inclusive Care for the Elderly (PACE) for contract year (CY) 2026. The MA Part D rule is released annually to incorporate updates in program administration, payment methodologies, and policy refinements to these programs. A fact sheet accompanied the release of the final rule.
Several of the policies that SGO supported, including improving experiences for dual eligible enrollees by using a single ID card for Medicare and Medicaid and requiring a single health risk assessment that is valid across both programs, were finalized.
However, the agency failed to implement or even address any of the proposed policies on guardrails for the use of artificial intelligence that would have ensured equitable access to MA services. The SGO supported all of the proposed AI guardrail policies that were meant to ensure that when artificial intelligence is used, whether it be for approving or denying prior authorizations, mining data to gather information on appointments made and canceled (a specific example that was discussed in the rule), or when AI is used in any fashion, that AI must be used in a manner that preserves fair and equitable access to MA services.
Additionally, the agency did not finalize or address any of the proposals that would have required MA plans to conduct an annual health equity analysis of utilization management policies and procedures. The SGO also supported these proposed policies.
Finally, the SGO supported the proposed coverage of anti-obesity medications, but this was also not finalized, nor discussed in the rule.
For the policy not addressed in the rule, the agency did note that they “may address these proposals in future rulemaking, as appropriate.”
We note that several policies were finalized that are meant to protect MA plan beneficiaries and improve MA beneficiaries’ experiences. New policy includes restricting MA plans from modifying or reopening for review, a previously approved inpatient hospital stay/procedure coverage decision when additional information was gathered after the approval. MA plans “will have to honor a prior authorization” regardless of patient information gathered. Finally, the agency will modify existing regulations to ensure that MA plan enrollees “liability to pay for services” cannot be decided until a claim is adjudicated by the MA plan with the contracted provider. Per the fact sheet, “this ensures that an enrollee has the right to appeal MA plan coverage denials that affect their ongoing course of treatment.”
The SGO has prepared a summary of the final rule that can be found here.