CMS Issues Final Rule Closing Medicare Advantage Loopholes

On April 4, the Centers for Medicare and Medicaid Services issued a final rule making policy and technical changes to the Medicare Advantage (MA) program, Medicare Prescription Drug Benefit program, Medicare cost plan, and Programs of All-inclusive Care for the Elderly for contract year 2026.

The final rule seeks to close MA loopholes that have adverse consequences for providers and enrollees. It clarifies the definition of “organization determination,” which is a decision subject to MA appeal and notification requirements, to include MA plan decisions made concurrent to the enrollee’s receipt of services. Additionally, it codifies existing guidance that requires plans to give both a provider and an enrollee notice of a coverage decision whenever the provider submits a request on behalf of an enrollee. Finally, it modifies existing regulations to clarify that an enrollee’s liability to pay for services cannot be determined until an MA organization decides on a contracted provider’s claim for payment.

CMS notes that certain provisions from the proposed rule, such as the annual health equity analysis of utilization management policies and artificial intelligence guardrails, will not be finalized at this time.

Sources: https://www.cms.gov/newsroom/fact-sheets/contract-year-2026-policy-and-technical-changes-medicare-advantage-program-medicare-prescription-final