Highlights of the CY2026 Medicare Advantage & Part D Proposed Rule

On November 26, 2024, the Centers for Medicare & Medicaid Services (CMS) released their Medicare Advantage (MA) & Part D Proposed Rule for Contract Year 2026. Here’s your Medicare news brief of important CMS updates.

With their Proposed Rule, CMS aims to hold MA and Medicare Part D sponsors more accountable for delivering high-quality coverage to Medicare-eligible beneficiaries. In the 714-page document, CMS outlines various policies and procedures that, if included as written in the Final Rule, will impact you, the carriers you represent, and your clients.

Here are the proposed rules we believe would most affect agents. Explore more by reading the CMS Fact Sheet and 2026 MA & PDP Proposed Rule on the Federal Register.

Proposed Protections to Enhance Informed Choice

CMS is continually working to make sure Medicare beneficiaries understand their options and plan choices fully. To enable individuals to make informed choices, they propose two new protections that would impact the way you do business.

Promoting Informed Choice Through Agent Marketing & Communications Requirements

In response to continued complaints about misleading and non-compliant advertisements, CMS proposes changing their definition of “marketing” (again) to increase the number and type of advertisements that must be submitted to CMS for review before use. This update follows the trends of recent years, with CMS refining their marketing definition to manage third-party marketing organizations (TPMOs), limit the use of the word “Medicare,” and regulate mentions of added benefits (like dental), among others.

Under the current requirements, materials and activities are considered “marketing materials” if they meet the “intent” and “content” requirements as described in §§ 422.2260(2) and 423.2260(2) of the marketing definition. If an ad is general and the material doesn’t meet the CMS “content standard,” it does not qualify as “marketing material.” So, TPMOs, of which agents are a part, do not need to submit the ad to CMS for review and approval before use.

CMS is proposing to eliminate the “content standard” so that all communications materials and activities that meet the existing “intent standard” are considered marketing for purposes of CMS’ MA and Part D marketing and communications regulations. Thus, such materials will be subject to the CMS’ HPMS filing requirement. By broadening their definition and review process, CMS hopes to better ensure Medicare-eligible individuals do not receive misleading, inaccurate, or confusing information.

Promoting Informed Choice by Discussing Programs to Help Beneficiaries

Since 2023, CMS has required agents to discuss a defined list of topics with clients before enrollment in a new MA plan. For CY2026, CMS wants to add two topics to their Pre-Enrollment Checklist, better ensuring an individual’s insurance options are fully discussed before an enrollment decision is made.

These new topics include:

• A person’s potential eligibility for the “Extra Help” Part D Low-Income Subsidy (LIS) and Medicare Savings Programs
• The potential impact MA enrollment might have on future Medicare Supplement (Medigap) guaranteed issue rights

Additionally, an agent would need to notify a client where they might find additional information about these subjects. Medicare.gov/basics is a good place to start.

Improved Experiences for Dually Eligible Enrollees

CMS has taken recent strides to improve the coordination and integration of Medicare and Medicaid for dual-eligible enrollees. For CY2026, CMS proposes new federal requirements for certain dual eligible special needs plans (D-SNPs) that would:

• Create integrated member ID cards that would serve as ID cards for both an enrollee’s Medicare and Medicaid plans
• Allow for an integrated health risk assessment (HRA) for Medicare and Medicaid, rather than separate HRAs for each

Furthermore, CMS also proposes codifying timeframes for all SNPs to conduct HRAs and individualized care plans (ICPs) and increasing the involvement of the enrollee (or representative) in the development of the ICP.

Automatic Renewal Enrollment into the Medicare Prescription Payment Plan

As part of the Inflation Reduction of 2022 and beginning in 2025, your clients have the option to spread out the cost of their prescription drugs over the course of the year instead of paying for it all up front at the pharmacy. The Medicare Prescription Payment Plan may help Part D enrollees who have high cost-sharing earlier in the plan year.

CMS published final part one guidance and final part two guidance for the Medicare Prescription Payment Plan in 2024. In their CY2026 Proposed Rule, CMS wants to codify the guidance for 2026 and beyond. Additionally, CMS proposes an automatic election renewal process that would extend a participant’s current enrollment into the next calendar year, unless the enrollee opts out.

Finally, CMS would like feedback on a potential requirement for Part D carriers to effectuate phone or web election requests in real-time for 2026 or future years. If interested, you can submit comments to CMS here.

Coverage of Anti-Obesity Medication

Since the creation of Part D, CMS has excluded medication used for weight loss in its definition of a covered Part D drug. With their Medicare Proposed Rule, they re-evaluate this exclusion considering the prevailing medical consensus that recognizes obesity as a disease.

CMS proposes to permit coverage of anti-obesity medications for the treatment of obesity when such drugs are indicated to:

• Reduce excess body weight
• Maintain weight reduction long-term

This reinterpretation does not include overweight individuals, since overweight is not considered a disease. If passed, it would also reinterpret the similar Medicaid statue. This means your clients struggling with obesity may have their anti-obesity drugs covered under their Medicare Part D plans in the future.

Equitable Access to Behavioral Health Benefits

CMS continues taking steps to improve access to behavioral health by ensuring that cost-sharing in MA and Section 1876 Cost Plans may be no greater than the cost sharing in Original Medicare. CMS believes that equalizing the cost sharing limits will “strike the appropriate balance between individual affordability and minimizing disruption to MA enrollees’ access to care and coverage options.”

Here are the current cost-sharing standards and proposed updates:

• Mental health specialty services, psychiatric services, partial hospitalization/intensive outpatient services, and outpatient substance abuse services: 30 to 50% 20%
• Opioid treatment program services: 50% 0%
• Medicare Fee-For-Service (FFS) cost sharing for inpatient hospital psychiatric services: 100 to 125% 100%

CMS is soliciting feedback on a possible transition period for implementing these proposed cost-sharing standards to avoid disruption in carrier operations.

Other Proposed Changes to Medicare

Above are the parts of the CMS Proposed Rule that will impact agents and their clients the most, but they are not all the proposed changes. The remaining proposals will affect carriers more and include:

• Strengthening and/or creating guardrails around prior authorization, utilization management, and artificial intelligence
• Adding provider directories on Medicare Plan Finder
• Regulating administration of supplemental benefits coverage through debit cards
• Updating MA and Part D medical loss ratio reporting
• Requiring Part D carriers to provide contracted pharmacies with information about networks before open enrollments
• Reminding Part D carriers and their pharmacy benefit managers that they are required to have in place a cost-effective drug utilization management program to provide broad access to generics, biosimilars, and other lower-cost drugs
• Expanding the criteria list of core chronic diseases for the development of the Medicare Therapy Management program
• Promoting community-based services and improving transparency of in-home service contractors

To read further about these proposed changes, please see the CMS’ press release. Subscribe to the Ritter blog using the form on this page to keep up to date on further posts detailing CMS guidelines and rulings.

As always, Ritter Insurance Marketing aims to keep our agents abreast of any important CMS press release or update and help them be compliant in their insurance business. If you have any questions about compliance, please reach out to our Compliance team. Register with us for free to gain access to all our resources and CMS-compliant technology.