What's in the rest of the Medicare final rule for 2027?

Spring has sprung, and so has CMS’s final word on the Medicare rules for CY 2027. We already dropped the heavy hitters in our previous insight, but that doesn’t mean there isn’t more to say. What got finalized, what didn’t, and what does that mean for you or your agency?

How will Star Ratings change in coming years?

CMS had proposed some changes to how star ratings were calculated, with 12 ratings either getting streamlined or chopped completely. Only the diabetes eye exam care will remain intact after all is said and done. The rest of the provisions mentioned will be removed in phases between 2027 and 2029. They are listed below:

Then, the proposed depression screening and follow up measure will be added for 2029.

While all the dust clears through these star rating shuffles, the medication adherence measurements will temporarily pause the weight on their scores until 2029.

The Health Equity Index, as proposed, will be removed. Currently, this reward gives out bonus points to a plan’s star rating if they have high scores in areas with certain risk factors. Now, once this index is removed, plans will not get extra credit for meeting standards in risky areas.

Cannabis can-a stay, sort of

So the rule proposed at first to eliminate any cannabis products from being covered by SSBCI in any form, as it was considered a federally illegal substance. But, since then, the definition of cannabis was refined, and now hemp derived products are not considered cannabis anymore. To reflect that change, the finalized rule will still prohibit coverage of cannabis products, but hemp derived products will be just fine. This will affect about three ingredients that find their way into items that could be covered.

Speaking of SSBCI, requirements for written, objective criteria for chronic illness determinations are now mandated. Before this, they were just suggested.

D-SNP changes

Beneficiaries can only be passively enrolled into a new DSNP if that new plan is managed by the same organization as their Medicaid benefits. When that happens, beneficiaries must get a minimum of 120 days of continuity of care as they transition to the new plan. This ensures that nobody is immediately cut off from any care or benefits they need and have time to make additional arrangements.

HIDE SNPs, while starting to make their way into the scene already, will be required in 2027. That means single ID cards for DSNP beneficiaries as well as one single Health Risk Assessment.

Supplemental Benefit cards

Supplemental benefits, like OTC cards, are a super popular item for Medicare beneficiaries. These will now be required to be administered to beneficiaries on a debit card, as most of them already have been.

While we will mostly keep what went unmentioned in the final rule to the end, it seems worth mentioning now that OTC card amounts were proposed to be off the table for marketing purposes in this rule. But, that portion was not mentioned again in this final rule. Therefore, marketing a plan with a “$x dollar a quarter OTC card” is still allowed for now.

Mid year supplemental benefit reminders will be no longer

Data did not support that beneficiaries were not using their supplemental benefits because they were unaware of them. Instead, if they went unused it was likely the benefit was unwanted. So CMS thinks a reminder is just a unnecessary cost at best and causing confusion at worst.

Some employer plans will be exempt from creditable coverage notices

Creditable coverage has been a hot topic ever since the IRA changed the max out of pocket for drug costs. Since the OOPM for a plan couldn’t be higher than the $2,100 max for 2026, many employer plans were not considered creditable as their out of pocket maxes often creeped upwards of that.

It was proposed to no longer require plans with HRAs, FSAs, and HSAs to provide creditable coverage disclosures, since they weren’t actually providing any coverage per se, just a way to pay for those drugs. And so, they are officially excluded from that disclosure requirement.

IRA is here to stay

The Inflation Reduction Act will be set into stone, eliminating:

• The Part D coverage gap
• Part D cost sharing in the catastrophic phase

And making permanent:

• The calculation method of the reduced out of pocket max
• The changes to the discount program
• TrOOP cost calculation methods
• Specialty drug tier rules
• The reinsurance payment processes
• The Select Drug Subsidy
• $0 vaccines
• $35 insulin

What was blocked?

This year, only one proposed rule was completely blocked: the provider termination SEP.

CMS had proposed an SEP for a beneficiaries if their provider leaves the network area. Assumingly, this was so beneficiaries could either choose to get a new plan allowing them to continue seeing that provider, or get a new plan with a new provider they would like to see. CMS has struck that idea down, and while they say it could be brought back up again in the future, it is blocked for now.

What was left out?

Some things were left out of this final ruling in lieu of getting flat out blocked. This might mean they will be addressed later, but for now, they will not be finalized.

CMS did not want SEPs created outside of official ruling last proposal. In the past, CMS would sometimes create new SEPs for exceptional circumstances, but the word on if this practice is actually banned going forward is mum.

So how does this affect my agency?

Most of what we talked about in our previous insight will do wonders for your agency in regards streamlining your processes overall, so check there if you haven’t already.

But for these more niche rules, most will not affect your day to day. Would it have been nice to have another way to get your clients into a more appropriate plan when their favorite specialist retires? Sure. Will the star rating shake up how your prospects view the plans you present them? Possibly. But for the most part, these things will have little impact on your business as a whole. Most of these rules will be affect with either the next plan year or Oct 1, 2026.