Journal
April 30, 2025cms.gov

CMS Releases Final 2026 Medicare Advantage Rule

What's it say

CMS recently released its final 2026 Medicare Advantage (MA) rule, addressing certain provider appeal rights but leaving several important issues unresolved. Under new CMS administrator Dr. Mehmet Oz, there was uncertainty regarding protections around MA plans, especially concerning prior authorization and internal coverage criteria.

While the new rule clarifies appeal rights for inpatient care, it notably omits critical policies from earlier proposals that aimed to increase transparency in prior authorization practices and limit overly restrictive coverage criteria. Over 33,000 public comments were received, highlighting widespread concern, yet key issues remain undecided.

Stakeholders worry these delays leave providers and beneficiaries without essential protections against financially driven restrictions by MA plans.

Carol's comments

This final rule feels a bit like a pizza missing key toppings—it's edible, but not exactly satisfying! While improved clarity around appeals is helpful, delaying rules on transparency and internal coverage criteria might encourage Medicare Advantage plans to keep using prior authorization aggressively.

For beneficiaries seeking fewer hassles, traditional Medicare paired with a Supplement and Part D plan continues to offer more predictable coverage.

Why it matters to you

This rule matters because unclear policies might allow your Medicare Advantage plan to deny services more easily. Consider your tolerance for coverage restrictions when deciding between Medicare Advantage and traditional Medicare.

Source

https://www.cms.gov/newsroom/press-releases/cms-releases-final-2026-medicare-advantage-rule

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