News: CMS issues CY 2026 MA and Part D final rule, changes to IRA

CMS has issued a final rule detailing changes to the Medicare Advantage (MA) and Part D programs for the contract year (CY) 2026. It also contains substantial modifications and revocations to the Inflation Reduction Act of 2022 (IRA) put into place during the Biden Administration.

One notable change in the CY 2026 final rule includes a restriction on reopening and modifying previously approved inpatient hospital decisions. According to a CMS fact sheet, under the new rule, “MA plans will only be able to reopen an approved admission for obvious error or fraud.”

“The goal of this provision,” CMS insists, “is to ensure that if a plan approves an inpatient admission, it will have to honor the prior authorization.”

The CY 2026 final rule also includes provisions to close MA appeal loopholes. For example, CMS has clarified the definition of “organization determination”—“decisions that are subject to MA appeal and notification requirements”—to include MA plan decisions made concurrent to the enrollee’s receipt of services.

According to CMS, other provisions to MA loopholes include:

• Requiring plans to give a provider notice of a coverage decision, in addition to notifying the enrollee, whenever the provider submits a request on behalf of an enrollee
• An enrollee’s liability to pay for services cannot be determined until an MA organization makes a decision on a contracted provider’s claim for payment

Quite notably, the proposed rule also includes a technical re-definition of hierarchical condition categories: “The definition of Hierarchical Condition Categories [will be made with] reference to International Classification of Diseases (ICD) general rather than version specific (i.e., from ICD-9 to ICD).”

Additionally, CMS will substitute the terms disease codes with diagnosis codes and disease groupings with diagnosis groupings “to be consistent with ICD terminology.”

Finally, the CY 2026 final rule also contains cost-sharing changes to the 2022 IRA, including modifications to:

• Vaccines (“Medicare Part D deductible shall not apply to, and there is no cost sharing for, an adult vaccine recommended by the Advisory Committee on Immunization Practices and covered under Part D.”)
• Insulin (“The Medicare Part D deductible does 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 covered insulin product applicable cost-sharing amount.”)

Editor’s note: To read the CMS final rule, click here. To read the CMS fact sheet, click here. To read NAHRI’s coverage, click here.