CMS has released its final rule for Medicare Advantage and Part D for 2026, introducing several regulatory changes aimed at improving care coordination and beneficiary protections.
While the rule includes important updates, such as streamlining prior authorization processes and clarifying the use of supplemental benefits, it stops short of addressing two of the most closely watched issues: expanding coverage for GLP-1 medications and regulating the use of artificial intelligence in prior authorization.
Here are five things to know:
1. CMS will not move forward with expanding Medicare or Medicaid coverage for anti-obesity medications such as Ozempic and Wegovy. The agency cited concerns over a projected $35 billion increase in federal spending over the next decade, along with opposition from payers.
2. Despite growing interest from stakeholders, CMS declined to finalize rules that would establish guardrails around the use of artificial intelligence in prior authorization decisions. The agency indicated it may revisit the issue in future rulemaking.
3. Under the new rule, Medicare Advantage plans can no longer retroactively deny inpatient admissions that they previously approved — unless there is evidence of fraud or a clear administrative error. The move is intended to improve care consistency and reduce provider burden.
4. CMS has strengthened the prior authorization appeals process. Appeal rights now apply to decisions made during the course of care, not just before treatment begins. Additionally, providers must be notified of appeal outcomes when they submit coverage requests on behalf of patients.
5. Several provisions from the Inflation Reduction Act have been officially implemented, including the Medicare drug price negotiation program, zero cost-sharing for adult vaccines recommended by the Advisory Committee on Immunization Practices and a $35 monthly cap on insulin costs — a policy that began in 2023 and will continue annually.
Click here to read the 438-page final rule in full.
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