Last Friday, the Centers for Medicare & Medicaid Services (CMS) issued a final rule regarding Medicare Advantage (MA) and Medicare Prescription Drug (Part D) policy. The rule will take effect in 2026. Of note, the final rule does not call for Medicare coverage of Ozempic or other anti-obesity drugs for people seeking to lose weight, as proposed, nor does it put guardrails on insurers’ use of artificial intelligence to deny care.
CMS chose not to finalize provisions in the Biden Administration’s proposed rule related to promoting equity, ensuring equitable access to MA services, imposing guardrails for artificial intelligence (AI) or covering anti-obesity medicines.
The rule does require MA plans to cover inpatient hospital admissions that they approved based through a prior authorization process. MA plans have too often decided post prior authorization approval to deny coverage for inpatient admissions that they deemed, after the fact, should have been treated as outpatient admissions. MA plans can only reopen a prior approval of an inpatient admission because of fraud or administrative error.
CMS also finalized a rule ensuring that enrollees and providers can appeal an MA denial whether it comes before, during or after a procedure.
CMS finalized a proposal that prohibits Medicare Part D plans from charging a deductible or copay for adult vaccines that the Advisory Committee on Immunization Practices recommends. The deductible also does not apply to insulin products; and, cost-sharing for these products cannot go above $35.
In addition, Part D plans must allow enrollees to make monthly payments for their covered drugs over the course of the year, rather than in one lump sum at the pharmacy. Effective this year, these payments cannot exceed $2,000 over the course of the year.
Here’s more from Just Care:
- Does UnitedHealth use flawed AI to deny care in Medicare Advantage?
- Louisiana: Medicare Advantage denials harm patients, while gouging taxpayers
- Medicare Advantage costs and prior authorization rules impede access to care
- Medicare Part D drug costs: What to expect in 2025
- 2025: Programs that lower your costs if you have Medicare
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