On April 4, 2025, CMS released the Final Rule for Medicare Advantage and PDP plans applicable to coverage beginning January 1, 2026. The provisions in the final rule are relatively brief with CMS finalizing only a select number of policies. Much was left unaddressed and additional proposals are expected to be finalized in the future.
Ruling Codifies Several Provisions in the Inflation Reduction Act
The final ruling codifies several IRA provisions that were due to expire at the end of 2025. Included in these are:
Adult Vaccine Cost Sharing
There must be $0 cost share for adult vaccines. The Medicare Part D deductible will not apply to any vaccine recommended by Advisory Committee on Immunization Practices (ACIP). Part D sponsors may not implement utilization management, step edits, National Drug Code blocks or specify a preferred brand of vaccine that would impact access to vaccines.
Insulin Cost Sharing
The Medicare part D deductible will not apply to covered insulin products and the Part D cost sharing amount for a one month supply of each covered insulin product must not exceed the applicable copayment amount which is $35 in 2025.
In 2026 and subsequent years the applicable cost sharing amount for a covered insulin product prior to the enrollee reaching their annual out of pocket threshold will be the lesser of:
- $35
- An amount equal to 25% of the maximum fair price or
- An amount equal to 25% of the negotiated price.
New Requirements for Medicare Prescription Payment Plan
PDP and MAPDP plans must offer enrollees an MPPP with the option to pay their cost sharing in monthly capped amounts over the course of the year. There are two new requirements for 2026:
Automatic Renewal Process and Notice
Current participants in a MPPP will automatically be renewed unless they choose to opt out, eliminating the need for new paperwork each year. The renewal notice must be sent after the end of the annual coordinated election period but before the beginning of the plan year.
Voluntary Termination Effective Date
Part D sponsors must send the notice of voluntary termination within 10 calendar days of receipt. The effective date of termination must be within three calendar days of the voluntary termination request.
Clarifying MA Determinations to Enhance Enrollee Protections in an Inpatient Setting
This ruling is meant to clarify MA organization determinations and will restrict MA plans ability to reopen and modify a previously approved inpatient hospital decision based on information gathered after the approval. An approved admission can only be reopened due to an obvious error or fraud.
Closing MA Appeals Loopholes
This ruling is intended to close loopholes that inadvertently affect providers and enrollees. It states the following:
- Appeals rules will apply to adverse plan decisions regardless of whether the decision was made before, during or after receipt of services
- Plans are required to give a provider notice of a coverage decision, in addition to the enrollee whenever a provider has submitted a request on behalf of the enrollee.
- An enrollee cannot be held liable to pay for services until the MA plan has made a decision on a contracted providers claim for payment. This ensures the enrollee always has the right to appeal denials that affect their ongoing treatment
Improving Experience for Dual Eligible Enrollees
In order to reduce fragmentation and simplify access to care for D-SNP enrollees, CMS is finalizing two new requirements for D-SNP plans to be fully integrated by 2027. This will require:
- One member identification card that serves as the ID card for both Medicare and Medicaid.
- One integrated HRA for Medicare and Medicaid rather than separate assessments for each program.
Other Updates From CMS
CMS has withdrawn proposed changes to the SEP for government declared disasters and emergencies that was to be effective April 1, 2025. Plans should continue to accept applications and continue to use current enrollment forms and plan materials that include the disaster/emergency SEP.
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