Proposed rule would establish more guardrails for Medicare Advantage

WASHINGTON – CMS is proposing changes to the Medicare Advantage (MA) and Medicare Part D prescription drug programs to hold them more accountable for delivering high-quality care for people with Medicare. 

In the Contract Year 2026 MA and Part D proposed rule, CMS proposes addressing inappropriate use of prior authorization and internal coverage criteria, including by defining the meaning of “internal coverage criteria” to clarify when MA plans can apply utilization management, ensuring plan internal coverage policies are transparent and readily available to the public. In addition, the agency is working to collect detailed information from initial coverage decisions and plan-level appeals, such as decision rationales for items, services, or diagnosis codes, that will provide a better line of sight on utilization management and prior authorization practices. 

“Our loved ones with Medicare deserve care that puts their interests first,” said HHS Secretary Xavier Becerra. “HHS is proposing to improve transparency, accountability, and consumer protections in Medicare Advantage and Part D plans so that everyone receives high-quality care. To achieve that, we want to remove barriers that delay care or deny people services and medications they need to be healthy. In addition, we continue to promote competition for pharmacies and other health care businesses.” 

The rule would also increase guardrails on the use of artificial intelligence (AI) to protect access to health services. 

• To review or comment on the CY 2026 MA and Part D proposed rule during its 60-day public comment period, visit the Federal Register . Comments must be submitted no later than Jan. 27, 2025. 

• For more information on the CY 2026 MA and Part D proposed rule, view the fact sheet.