CMS publishes the proposed Medicare rules for 2026

Last month, we discussed the Marketplace proposed rules for 2026. On November 26, CMS released its proposed Medicare rule for 2026. Between changes to Part D, stricter marketing material guidelines, and rules around AI, more than a couple of things might be changing. Let’s see what’s in store. 

More marketing material would need review

It’s still happening, folks: advertisements for MA plans are still being found as misleading. To help combat this, CMS is broadening the scope of what materials would require their review. In short, any marketing piece trying to draw a beneficiary to contact and inquire about a plan would require review by both the plan and CMS. This is a huge departure from the current state, where marketing pieces must meet both content and intent standards to trigger CMS review.

An ad touting “Questions about your Medicare options? Call 1-800-LEARN-MORE” would need approval, for example. The ad's intent is to sway the reader to call and ask questions about MA plan details.

So, CMS wants to reign it in a whole lot more. Any ad with “call us to talk about MA/Part D plans,” as the call to action will need CMS approval. CMS admits many ads will now need approval that did not in the past.

Specifically regarding marketing, plans will no longer be able to market the dollar value or the administration method of their supplemental benefits directly to beneficiaries.

Agents/brokers have more to talk about in each appointment

CMS wants agents to be more aware of beneficiaries who qualify for subsidies. To do this, they propose adding Low-Income Subsidy and Medicare Savings Programs eligibility to the list of required discussion points when working with a beneficiary. To ensure consumers are aware of their Medicare Supplement options, CMS would add a discussion of guaranteed issue rights and the implications of switching from Medicare Advantage to Traditional Medicare – and vice versa. Brokers would specifically be required to inform beneficiaries of their 12-month trial right period, in which they may enroll in an MA plan and switch back to Traditional Medicare with a Medigap plan. This requirement would only apply to MA sales; not prescription drug plans.

GLP-1 coverage

Due to The Medicare Prescription Drug Improvement and Modernization Act (MMA) of 2003, Part D is currently prohibited from covering any drug used only for weight loss. It could be prescribed to treat something else, just not weight loss. Often, the super-popular Ozempic is prescribed for, say, type 2 diabetes, and the beneficiary would happen to lose a few pounds in the process. 

But, medical research continues to find more positives to treating the cause of medical issues instead of the symptoms. One study found that if Medicare willingly covered GLP-1s for weight loss in addition to the current status quo, it would save taxpayers $245 billion in a decade. Less obesity would result in fewer beneficiaries needing treatment for its related conditions.

CMS proposes that anti-obesity medications like Ozempic or Wegovy be covered for the purpose of long-term weight reduction for obese beneficiaries. This brings obesity one step closer to being treated as a chronic disease. CMS was clear, though, that being overweight is not the same as being obese, and only those considered obese would have these drugs covered. This extension would also apply to Medicaid. 

Prescription drug payment plan

The prescription drug payment plan is a hit. CMS wants to make the program permanent in 2026 and beyond. To that end, beneficiaries would automatically stay in the program each year, unless and until they opt out.

Part D changes

CMS wants Part D to be a bit easier and more fair to all parties. CMS reminds plan formularies that biosimilars, generics, and other low-cost drugs must be broadly accessible. Dementia treatments will be added to the medication management program.

Pharmacies

Carriers must let pharmacies know which plans are considered in-network before October 1 each year. Pharmacies will be granted the same freedom as plan sponsors and will be able to terminate network contracts without cause. Pharmacy network contracts would also require pharmacies to enroll in a CMS system promoting access to negotiated fair maximum prices, which would also help ensure accurate claims and payment.

Insulin and vaccines

A bit of a change to how insulin will be covered is coming in 2026. CMS proposes that insulin covered under a PDP or MA-PD plan will be covered at one of three different thresholds: $35 per month, 25 percent of the maximum fair price, or 25 percent of the price negotiated between the plan and the manufacturer. This price would be used prior to the beneficiary reaching the out-of-pocket threshold.

The Part D rules from the Inflation Reduction Act will go into play, and vaccines recommended by the Advisory Committee on Immunization Practices (ACIP) will no longer be exposed to cost sharing or deductibles. 

Prior authorizations

A need for more checks and balances is seen by CMS when it comes to prior authorizations. Denials have been on the rise, and are overturned about 80% of the time. Beneficiaries are experiencing unjust barriers to care too often for CMS’s taste, so gathering more data to see what can be improved upon is in order. In addition to the clarifications published earlier this year, CMS will take additional steps.

First, if a beneficiary isn’t responsible for paying for an MA-plan service, the determination does not need to follow the standard appeal process. A beneficiary’s payment responsibility cannot be determined until the MA plan requests the beneficiary pays. 

Second, CMS would like to refine the definition of an organization determination. While a beneficiary is receiving care, decisions about the level of care made by the MA organization are subject to appeal, just like any other service requiring prior authorization. 

Third, notice of an MA organization’s decision must be given to a provider when they have made a standard or integrated organization decision on the beneficiary’s behalf. 

Last, MA organizations will no longer have the ability to reopen an authorization for inpatient hospital care that has already been approved. 

Supplemental benefit cards

79 billion dollars is predicted to be spent in 2026 on supplemental benefits, and CMS wants to make sure that money is being used effectively. 

CMS proposes MA plans should offer more guidance to beneficiaries on how to use the debit cards supplemental dollars are generally distributed on. These cards should have clearly labeled over-the-counter items and locations directly linked to them. And, where the cards are used to offset cost-sharing for services, the cards should be linked to plan information to ensure the service is covered. If the debit card is on the fritz, an alternative must be provided. MA plans would also be prohibited from marketing both the dollar value of these benefits and the method by which these benefits are used. They could not, for example, advertise a “$65 per month Medicare flex card.” 

Combining Medicare/Medicaid cards

Beneficiaries have too many cards! Where integrated D-SNPs exist, CMS wants to combine Medicare and Medicaid cards for enrolled beneficiaries. Health risk assessments would be combined as well.

Medicare Plan Finder (MPF)

The Medicare Plan Finder tool can be cumbersome for beneficiaries to use when searching for provider network information. CMS sees the fix: require MA organizations to give provider directories to CMS. This way, they can be made searchable and added to the MPF. These directories must be accurate within 30 days of a change. 

Medical Loss Ratio (MLR)

Medical loss ratio reporting will be fine-tuned as well to make plans easier to compare. The tweaks would include things like what can and cannot be included in the MLR, what information can be requested, and what can happen if a provider gets audited. 

Behavioral health 

Mental health matters, and that is reflected in CMS’s proposal. MA plans’ cost sharing for behavioral health must not be greater than cost sharing for Traditional Medicare. A 20% coinsurance or equivalent copayment limit is proposed for these services and outpatient substance abuse services. Zero cost sharing for opioid treatment is also on the table. Cost-sharing for inpatient psychiatric services would be capped at 100% of the fee-for-service rate.

AI in the health space

The current administration has already written some guidance on the use of artificial intelligence tools in the MA space. CMS wants to add that MA plans must provide services equally and not discriminate against a beneficiary due to health status, regardless if the service was provided by a human or an automated system.

Conclusion

CMS wants to have both eyes on your marketing, particularly TV ads and social media content. The masses have spoken about Ozempic and friends, and CMS heard them loud and clear while still trying to keep some hands on the reigns. We’re going to keep reading more clarifications as they roll out and pass the facts on to you. If you want to leave a comment on the proposed rules, you can do so regulations.gov Make sure to get your two cents in by Jan 27 when comments close.