In its continual effort to enhance the quality and accessibility of healthcare services, the Centers for Medicare & Medicaid Services (CMS) has introduced a comprehensive proposed rule for the contract year 2026. The proposal, titled “Contract Year 2026 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicare Cost Plan Program, and Programs of All-Inclusive Care for the Elderly,” aims to tackle many critical issues within the current healthcare system.
AI and Discrimination in Healthcare
One of the primary focuses of the proposed rule is the prevention of discrimination and inequities in treatment arising from the use of AI tools in the healthcare system. The CMS has raised concerns about incomplete medical records and scheduling issues potentially leading to discriminatory practices. To address this, the proposal mandates that Medicare Advantage (MA) organizations ensure their AI or automated systems do not discriminate against enrollees based on their health status. Furthermore, MA organizations will need to regularly review their AI systems to check for biases, ensuring fair and equitable treatment for all beneficiaries.
Coverage of Anti-Obesity Medications
In a landmark move, the proposal includes provisions for the coverage of anti-obesity medications (AOMs) under Part D and Medicaid programs, starting from the contract year 2025. This significant change will benefit millions of enrollees with obesity by providing them with access to necessary medications, potentially reducing the overall burden of obesity-related diseases. CMS plans to reinterpret the statutory exclusion of weight loss agents to include drugs for treating obesity, acknowledging it as a disease.
Medicare Marketing Rules
Addressing the growing issue of misleading marketing practices, CMS proposes an expansion of the definition of marketing to encompass materials that draw attention to or influence decisions about MA and Part D plans. This broadened definition aims to close loopholes and provide CMS with stronger oversight capabilities. With these new rules, CMS can act promptly against non-compliant advertisements, protecting beneficiaries from deceptive and potentially harmful marketing practices.
Supplemental Benefits Administration
CMS aims to enhance transparency and accessibility by codifying existing standards and introducing new requirements for the administration of supplemental benefits through debit cards. Plans will need to provide clear instructions and customer support for using debit cards linked to plan-covered benefits while ensuring that expenses are limited to covered services. This initiative seeks to empower enrollees by ensuring they understand how to access and utilize their benefits effectively.
Equitable Behavioral Health Service Access
The proposal includes measures to reduce cost-sharing barriers for behavioral health services, requiring MA and Cost Plans to set in-network cost-sharing at no more than traditional Medicare levels by January 2026. This move is particularly significant in light of the disruptions and cost barriers for mental health services exacerbated during the COVID-19 pandemic. By making behavioral health services more affordable, CMS hopes to improve access to vital mental health support for enrollees.
Provider Directory Data Transparency
To enhance transparency and ensure plan data accuracy, CMS will require MA plans to submit provider directory data to Medicare Plan Finder (MPF). This data will include detailed information about community-based and in-home service providers, enabling enrollees to identify providers who can deliver services in their homes. These measures aim to improve the accuracy of provider directories, ensuring enrollees have reliable access to essential healthcare information.
Star Ratings Updates
The Centers for Medicare & Medicaid Services (CMS) have always strived to improve healthcare quality and accessibility. In line with this mission, CMS has unveiled a comprehensive proposed rule for the contract year 2026. This proposal is titled “Contract Year 2026 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicare Cost Plan Program, and Programs of All-Inclusive Care for the Elderly.” The aim is to address several critical issues in the current healthcare system. There are significant concerns that the new rule aims to address, which include enhancing patient care, ensuring better access to medications, and improving coordination across various healthcare programs. By focusing on these critical areas, CMS intends to make healthcare services more efficient, effective, and accessible for all beneficiaries. This initiative illustrates CMS’s commitment to evolving the healthcare system to meet modern needs while ensuring that no one is left behind.
