On Nov. 26, CMS proposed reforms to the Medicare Advantage and Part D programs for contract year 2026, including changes to prior authorization and GLP-1 coverage.
Here are 10 things ASC leaders and physicians need to know about the proposed reforms:
1. The agency is seeking feedback on how MA medical loss ratios are calculated in order to address concerns surrounding vertical integration across the industry.
2. Part D plans and Medicaid programs may provide coverage of GLP-1s for obesity after previously being excluded.
3. CMS is looking to "address concerns about the overuse of prior authorization" by clarifying definitions for internal coverage criteria, creating stricter transparency requirements for payers, ensuring enrollees are informed about their rights to appeal and collecting more data on initial coverage decisions and appeals.
4. CMS is proposing new standards for MA medical loss ratio reporting to be more aligned with Medicaid and commercial requirements. This change seeks to address concerns regarding vertical integration in MA and Part D.
5. CMS is proposing an expansion of the definition of "marketing" to cover more materials and activities related to MA and Part D plans. It will require that more advertisements and communications be reviewed by the agency before being shared with the public. This proposal also focuses on improving consumer tools on Medicare.gov and will require brokers to discuss more topics, like Medigap rights and low-income subsidy eligibility.
6. The Medicare Plan Finder will include searchable provider directories for MA plans. MA organizations must update provider data within 30 days of changes and ensure accuracy through CMS compliance checks.
7. CMS looks to clarify rules regarding the use of debit cards for supplemental benefits, which will require transparency and alternative processes for covered services. Plans will not be able to advertise supplemental benefit dollar values or debit card usage prominently.
8. D-SNP plans must use integrated ID cards for Medicare and Medicaid and conduct unified health risk assessments.
9. CMS looks to enforce equitable access to care amid the increased use of AI in healthcare. MA plans using AI must comply with anti-discrimination laws and provide fair, unbiased access to services.
10. Plans must include in-home service providers in directories and specify which are affiliated with community-based organizations.