CMS Finalizes Policy Updates for the 2026 Medicare Advantage Contract Year

April 11, 2025

The Centers for Medicare and Medicaid Services (CMS) has issued a final rule updating policy requirements for Medicare Advantage (MA) plans for the 2026 contract year. While ASHA offered extensive comments in response to the proposed rule in an effort to ensure MA plans cannot continue to impose unreasonable utilization management techniques that create access challenges for Medicare beneficiaries (e.g., prior authorization), the vast majority of the proposals under consideration were not addressed or finalized in this rule.

ASHA remains committed to ensuring MA plans are held accountable for covering the Medicare benefit to maintain timely access to care for the patients our members treat.

CMS received nearly 32,000 comments on the proposed rule, showing the importance of MA coverage and the significant impact these plans have had on Medicare beneficiaries’ access to care. The requirements of this rule will be implemented on January 1, 2026.

Policies Not Finalized

ASHA submitted comments to CMS asking it to finalize proposals associated with:

Provider directory requirements for MA plans to ensure the information is accurate and up to date;
MA plan broker and agent requirements designed to ensure MA beneficiaries make informed decisions when selecting a plan;
Timely communication of changes to evidence of coverage documents; and
Transparency in the use of internally developed coverage policies.

Unfortunately, none of these policies were addressed in the final rule.

CMS also included a proposal regarding the use of artificial intelligence in coverage decisions. CMS acknowledged the comments it received but elected not to finalize a policy in this rule.

Improving Experiences for Dually Eligible Enrollees

CMS did elect to finalize new federal requirements designed to improve experiences for patients who qualify for Medicare and Medicaid. MA plans designed for these dually eligible beneficiaries―known as Dual Eligible Special Needs Plans (D-SNPs)―that are identified as applicable integrated plans must do the following:

Have integrated member ID cards that serve as the ID cards for both the Medicare and Medicaid plans in which a patient is enrolled; and
Conduct an integrated health risk assessment (HRA) for Medicare and Medicaid, rather than separate HRAs for each program.

CMS also finalized provisions to codify timeframes for special needs plans to conduct HRAs and individualized care plans (ICPs) and prioritize the involvement of the enrollee or the enrollee’s representative, as applicable, in the development of the ICPs.

What’s Next

CMS typically engages in an annual process to update policies for MA plans. ASHA will continue to monitor for and respond to proposed rules and other opportunities to inform policymakers—including CMS, MA plan sponsors, and Congress—on MA plans’ effectiveness in ensuring Medicare beneficiaries maintain access to care regardless of whether they are covered under traditional Medicare or an MA plan.