CMS releases 2026 Medicare final rule: What's missing matters most

On Friday, April 4, the Centers for Medicare and Medicaid Services released its final rule for Medicare Advantage and Part D programs in 2026. This rule is notable more for what it omits than what it includes. Many proposals from the previous administration weren't addressed, though as we've seen with Marketplace regulations, off-cycle rule-making remains possible. Let's examine what takes effect on June 3, 2025.

What agents need to know about the 2026 Medicare final rule

While few provisions directly impact how agents and brokers conduct business, several changes could benefit specific groups of beneficiaries, particularly dual-eligibles and those requiring in-patient care. If you’re serving these clients, knowing these changes will help you better guide them through their Medicare experience.

Streamlined care for dual-eligible clients

CMS has long recognized that dual-eligibles – those eligible for both Medicare and Medicaid – face a disjointed healthcare experience with separate systems, requirements, and cards. To help streamline access to care for these beneficiaries, CMS is finalizing three key adjustments to integrated D-SNPs (Dual Eligible Special Needs Plans), which provide both Medicaid and Medicare services to enrollees. These changes go into effect on January 1, 2027.

First, these plans will be required to issue a single member identification (ID) card that serve as identification for both the Medicare and Medicaid plans. This simple but important change eliminates confusion for both beneficiaries and providers about which card to present when seeking care.

Second, plans will be required to conduct an integrated health risk assessment (HRA) for Medicare and Medicaid, rather than two separate assessments. This reduces redundancy and paperwork burden while ensuring a more holistic view of the beneficiary's health needs across both programs.

Finally, timelines for both HRAs and the development of individual care plans are now clearly codified:

• Initial HRAs must be completed within 90 days of enrollment
• Annual HRAs must be completed within 365 days of the previous assessment
• Individual Care Plans must be completed within 30 days of the initial HRA or 30 days after enrollment, whichever occurs later

These changes represent meaningful improvements in care coordination for your dual-eligibles, though impacts will vary depending on which specific D-SNPs operate in your market.

Enhanced protections for in-patient clients

CMS has issued important new protections for Medicare Advantage beneficiaries in in-patient settings. Previously, CMS asked MA plans to give notice of a coverage decision to both providers and beneficiaries simultaneously. This practice is now embedded into federal regulations, giving it greater weight and enforceability.

Additionally, CMS has clarified that an enrollee's liability to pay for services cannot be determined until an MA organization makes a claims payment determination. This should help to curb some providers' practice of collecting payment for in-patient services before they are actually rendered – a practice that can cause financial hardship for beneficiaries who may later have claims denied.

Plans are also now explicitly forbidden from using information gathered after an admission takes place when reviewing whether an admission was appropriate in the first place. This is a significant protection against retroactive claim denials based on information unavailable at the time of admission. CMS expects this will reduce retroactive downgrading, while acknowledging costs of care may increase as a result.

When advising clients who frequently require hospital care, these protections may be worth highlighting as a positive development, particularly for those considering their options during the next Annual Election Period.

Vaccine and insulin coverage finalized

Beginning on January 1, 2026, these provisions will solidify implementation of various parts of the Inflation Reduction Act of 2022. Importantly, no cost-sharing, including the Medicare Part D deductible, will apply to adult vaccines recommended by the Advisory Committee on Immunization Practices (ACIP). This helps remove financial barriers to important preventive care for your clients.

The Medicare Part D deductible will also not apply to covered insulin products. And, until the beneficiary reaches the maximum out-of-pocket threshold in a given plan year, insulin cost-sharing for a one-month supply is limited to the lowest of these three amounts:

• $35
• 25% of the maximum fair price established for that product via the drug price negotiation program
• 25% of the negotiated price of the covered insulin under the Prescription Drug Plan (PDP) or Medicare Advantage – Part D plan (MAPD)

These provisions continue the trend of making insulin more affordable for Medicare beneficiaries – an important consideration for your diabetic clients when selecting plans.

Medicare Prescription Payment Plan adjustments

Each Part D enrollee must have the option to enroll in the Medicare Prescription Payment Plan, allowing them to spread their prescription drug cost-sharing responsibilities throughout the plan year. Through Plan Year 2025, CMS was able to administer this program through regular guidance. However, beginning with plan year 2026, CMS must legally use the formal rulemaking process.

To minimize disruption for both carriers and beneficiaries, CMS has largely codified the previous guidance as written. However, there are two notable improvements:

First, CMS will now allow beneficiaries to automatically re-enroll in the program for the next plan year. The notification timeline of this renewal will be slightly modified to take place between the end of the Annual Election Period and the beginning of the next plan year on January 1. This is intended to reduce beneficiary confusion, since only those who complete a new enrollment during AEP will be required to manually re-enroll in the program.

Second, CMS will require plans to ensure beneficiaries are enrolled in the program no later than 24 hours after their request, so they can take full advantage of the program on their future prescription fills. This provides faster access to payment spreading for beneficiaries who may be facing large prescription costs.

These changes make the payment plan more convenient for your clients who struggle with out-of-pocket prescription costs, while maintaining the core benefit of spreading those costs throughout the year.

If desired, plans must also unenroll beneficiaries from the program within 24 hours.

Technical updates worth noting

Several technical updates were included in the final rule that may have indirect effects on beneficiaries:

Prescription Drug Event reporting gets finalized

CMS codified timely submission requirements for Prescription Drug Event reporting – the process by which carriers file Part D claims with CMS. Carriers must submit claims within 30 days of a prescription being filled, and have another 90 days to either adjust or delete the claim if necessary. While not essential to your day-to-day work, this knowledge can help explain to beneficiaries why they may see a delay in carriers’ and CMS’ tracking of progress toward a Part D deductible or maximum-out-of-pocket threshold.

In-network pharmacies will be required to join the Medicare Transaction Facilitator Data Module

As part of the Medicare Drug Price Negotiation Program, CMS established the Medicare Transaction Facilitator Data Module (MTF). In short, the module exists to ensure drug manufacturers and pharmacies are charging only the Maximum Fair Price negotiated under the program. CMS hopes that by requiring in-network pharmacies to participate in the MTF, beneficiaries will be more likely to only pay their share of the negotiated price. And, should a beneficiary overpay, the MTF makes it easier to issue refunds to those beneficiaries.

Risk adjustment data updates

CMS finalized some technical changes to allow its guidance to remain consistent with ICD terminology as new versions of the International Classification of Diseases are released. CMS also codified a longstanding requirement of risk adjustment data collection and submission by PACE organizations and Cost plans.

What's notably absent from the 2026 Medicare final rule

There is a lot left on the cutting room floor. While we won't speculate on the rationale for all of the exclusions, CMS was clear that some cuts were made to help comply with Executive Order 14192, "Unleashing Prosperity through Deregulation."

Under that guise, CMS declined to finalize language on the following items:

• Health Equity Index Reward for Parts C and D Star ratings, which would have incentivized plans to track progress toward improving outcomes for some beneficiary groups
• Annual health equity analysis of prior authorization and other utilization management policies, which would have required plans to report on which demographics were impacted by those policies
• Requirements for plans to provide culturally and linguistically appropriate services
• Quality improvement and HRAs focused on equity and social determinants of health

CMS also declined to allow Part D coverage for GLP-1s like Wegovy and Ozempic for weight loss – a topic of increasing interest among beneficiaries as these medications gain popularity. The rule is also silent on regulations concerning the use of Artificial Intelligence in this market.

CMS did not codify any language that requires Part D sponsors to place biosimilars or generics on lower prescription tiers, though it did strongly encourage plans to do so. And, it did affirmatively state it will continue to monitor trends on formularies, reserving the right to make future rules in this area.

Most notably for agents and brokers, there was no mention of the marketing guidelines that would have removed the content standard and subjected more materials to CMS review. Therefore, you can expect to work under current rules – for the moment, at least. That means ads for your agency inviting beneficiaries to call and discuss their Medicare options still have the green light – just be sure to comply with other guidelines about educational and marketing content, too.

Additionally, the rule doesn’t address the proposed changes to the pre-enrollment checklist that would have required you to discuss the Low-Income Subsidy with every beneficiary. So that, too, will remain the same.

Much remains the same for now

In short, this final rule doesn't do much to re-shape the market for agents and brokers. There are no earth-shattering statements about broker compensation, field marketing organizations and overrides, or significant changes to marketing rules. The document is silent on the recent revival of CMS's 48-hour rule for Scopes of Appointment. And, it doesn't even mention the unscrupulous call centers that continue to be a challenge for agents who are committed to doing things the right way.

Business can continue largely as usual, with the understanding that these additions to the Medicare program – particularly those affecting dual-eligibles and in-patient settings – create new opportunities to demonstrate your value as an advisor to clients in those situations.

With Dr. Mehmet Oz recently confirmed to lead CMS, we may see supplemental rule-making telling us more about the administration's plans for the Medicare Advantage program in the near future. As always, we'll keep you informed of any developments that impact your business and client relationships.