The Medicare Rights Center has submitted comments on the proposed Medicare Advantage and Part D rule for 2026 from the Centers for Medicare & Medicaid Services (CMS). This annual rule introduces critical provisions aimed at strengthening prior authorization standards, enhancing transparency, and improving access to accurate plan information for beneficiaries. We strongly support these reforms and urge the new Trump administration to adopt them fully to protect Medicare enrollees and ensure fair healthcare access.
Limiting Overuse of Prior Authorization
A key provision in the proposed rule seeks to limit excessive use of prior authorization by requiring Medicare Advantage plans to base their internal coverage rules on clinically proven benefits rather than using them as barriers to care. CMS also emphasizes the need for greater transparency by requiring plans to disclose their prior authorization policies in a way that is easily accessible to the public. Additionally, the rule prohibits the use of blanket denials, whether through artificial intelligence or other automated systems, ensuring that no technology-driven mechanism can systematically restrict patient access to care.
Improving Provider Directory Accuracy in Medicare Plan Finder
Another major update would require MA plans to submit up-to-date provider directory data to CMS, allowing the information to be integrated into Medicare Plan Finder. This change would help enrollees find plans that include their preferred doctors and specialists, addressing the current challenge of inaccurate or outdated provider listings. Currently, beneficiaries must navigate individual plan websites to find this information, often encountering discrepancies that lead to confusion and potential gaps in care. By centralizing this data, CMS aims to increase transparency and simplify plan selection for Medicare beneficiaries.
Strengthening Marketing Regulations to Protect Consumers
To prevent misleading advertising and unethical marketing tactics, the proposed rule introduces stricter oversight of MA marketing materials. It would also prohibit plans from marketing debit cards as a benefit, a tactic that has often led to confusion among enrollees. Furthermore, agents and brokers would be required to inform consumers about important affordability programs such as the Low-Income Subsidy (LIS or “Extra Help”) for prescription drug costs and Medicare Savings Programs (MSP) for additional Medicare expenses. These requirements aim to prevent deceptive marketing practices and ensure that Medicare beneficiaries receive comprehensive and accurate information about their healthcare options.
Scrutinizing Anti-Obesity Medication Coverage
One of the more debated provisions in the proposed rule would expand Medicare Part D coverage to include anti-obesity medications. While the Medicare Rights Center supports broader access to essential treatments, we emphasize the need for cost-control measures to prevent excessive Medicare spending on these high-priced drugs. Encouragingly, some of these medications are being considered for Medicare’s drug price negotiation program, which could lead to significant cost reductions in the near future.
Commitment to Protecting Medicare Beneficiaries
These proposed reforms highlight important steps toward improving Medicare Advantage and Part D oversight. However, given that the rule was proposed under the Biden-Harris administration and will be finalized under the Trump administration, there is uncertainty about how many of these provisions will be implemented. Regardless of political transitions, the Medicare Rights Center remains committed to advocating for policies that enhance Medicare’s accessibility, affordability, and fairness. We will continue working to ensure that all beneficiaries receive the care they deserve without undue financial or administrative burdens.
Why Medicare Advantage and Part D Rule Reforms Matter for Medical Billing Companies
Medicare Advantage and Part D rule reforms significantly impact medical billing firms as they directly influence reimbursement policies, claim processing, and compliance requirements. These reforms, introduced by the Centers for Medicare & Medicaid Services, are designed to enhance transparency, improve patient access to care, and streamline billing processes.
One key aspect of these reforms is the tightening of prior authorization rules for Medicare Advantage plans, reducing administrative burdens and preventing unnecessary claim denials. Billing firm must adapt by ensuring accurate documentation and aligning their processes with the new requirements. Additionally, changes in Part D, such as formulary adjustments and cost-sharing modifications, affect how prescriptions are billed and reimbursed, requiring billing teams to stay updated on coverage policies.
Moreover, these reforms introduce stricter audit and compliance measures, making it essential for billing companies to maintain accurate coding and timely claim submissions. Failure to comply with updated regulations could lead to penalties or claim rejections.
By proactively adjusting to Medicare Advantage and Part D rule changes, medical billing outsourcing companies can optimize revenue cycle management, enhance efficiency, and ensure providers receive rightful reimbursements while minimizing claim denials and compliance risks.