Policy Corner: Proposed Changes to Medicare Advantage for 2026

The Centers for Medicare & Medicaid Services (CMS) has announced significant proposed changes to the Medicare Advantage (MA) and Medicare Part D prescription drug programs for Contract Year 2026. These changes aim to enhance protections and improve access to care for Medicare and Medicaid beneficiaries.

Decades-old legislation describing what CMS can and cannot cover expressly excluded weight loss drugs from mandatory coverage. However, the new proposed changes would reinterpret the statute to include coverage for anti-obesity medications under Medicare Part D and require Medicaid programs to cover these medications for obesity treatment. This change could benefit infusion and injection patients needing these medications as part of their overall treatment plan.

The Infusion Access Foundation and our advocacy partners have called for reforms related to MA prior authorization, utilization management, and coverage decisions for years. The proposed rule addresses these concerns regarding barriers to care and administrative burdens. CMS data shows that MA plans overturn 80% of their claim denial decisions when appealed, yet less than 4% of denied claims are appealed. This means that plans are putting unnecessary limits on access to care that could be overturned. A few key proposals in this rule include clarifying when MA plans can apply utilization management, ensuring coverage policies are transparent and available to the public, and requiring plans to make beneficiaries aware of their rights to appeal. These changes aim to remove unnecessary barriers to care resulting from inappropriate use of prior authorization and internal coverage criteria.

CMS proposes that MA organizations make their entire provider directory available on Medicare Plan Finder. The proposal comes in response to CMS hearing from MA enrollees that they have had difficulty accessing the care they need. This would allow infusion patients and caregivers to more easily compare provider availability across different MA plans, potentially improving access to specialized infusion care.

The proposed changes could significantly benefit infusion patients in multiple ways. First, they aim to reduce denials for necessary treatments and improve access to specialized care that requires prior authorization. Additionally, enhanced consumer tools on Medicare.gov and more comprehensive provider directory access will empower infusion patients to make better-informed decisions about their care. We hope these changes will improve the lives of infusion patients.

The public comment period for these proposed changes is open until January 27, 2025. Infusion patients and caregivers are encouraged to review the proposals and submit comments to ensure their unique needs are considered in the final rule. However, the Infusion Access Foundation will be sure to submit comments on behalf of our infusion patient and caregiver community.