The proposed rule also includes provisions to strengthen oversight of artificial intelligence use.
On November 26, 2024, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that would revise the Medicare Advantage (MA) Program, Medicare Prescription Drug Benefit Program (Part D), Medicare Cost Plan Program, Programs of All-Inclusive Care for the Elderly (PACE). The Contract Year (CY) 2026 MA and Part D proposed rule aims to hold MA and Part D plans more accountable for delivering high-quality coverage so that people with Medicare are connected to the care they need when they need it. This proposed rule includes more policies to remove unnecessary barriers to care stemming from the use of inappropriate prior authorization by clarifying requirements for plan use of internal coverage criteria and proposing guardrails for the use of artificial intelligence (AI) to protect access to health services.
Get more details on the Proposed Rule from CMS or view the rule in the Federal Register.
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 (CMS-4208-P) | CMS. (2024, November 26). https://www.cms.gov/newsroom/fact-sheets/contract-year-2026-policy-and-technical-changes-medicare-advantage-program-medicare-prescription
Siddiqi, Z. (2024, November 26). [UPDATED] CMS issues ‘Guardrails’ to improve Medicare advantage access and transparency. Skilled Nursing News. https://skillednursingnews.com/2024/11/breaking-cms-issues-guardrails-to-improve-medicare-advantage-access-and-transparency/
Early, B. (2024, November 26). Medicare Advantage prior authorization, marketing limits proposed. Modern Healthcare. https://www.modernhealthcare.com/policy/medicare-advantage-proposal-prior-authorization-brokers-glp-1s-cms
Berklan, J. M. (2024, November 26). BREAKING: CMS proposes more Medicare Advantage ‘guardrails’ – McKnight’s Long-Term Care News. McKnight’s Long-Term Care News. https://www.mcknights.com/news/breaking-cms-proposes-more-medicare-advantage-guardrails/
Berklan, J. M. (2024, November 27). ‘Inappropriate’ prior authorization targeted in latest CMS proposed rule, but will it ever go live? – McKnight’s Long-Term Care News. McKnight’s Long-Term Care News. https://www.mcknights.com/news/inappropriate-prior-authorization-targeted-in-latest-cms-proposed-rule-but-will-it-ever-go-live/
LeadingAge. (2024, November 27). LeadingAge Statement: Contract Year (CY) 2026 MA and Part D proposed rule (CMS-4208-P). https://leadingage.org/leadingage-statement-contract-year-cy-2026-ma-and-part-d-proposed-rule-cms-4208-p/
Improve Medicare Advantage reimbursements with payer contract management that puts payer rules in the hands of clinicians & billers.
