CMS Proposes Medicare Advantage and Part D Changes to Improve Access to Care

The Centers for Medicare & Medicaid Services (CMS) is proposing changes in 42 CFR Parts 417, 422, 423, and 460 related to the Medicare Advantage (MA) and Medicare Part D prescription drug programs to continue to strengthen protections and access to care for people with Medicare. For more information on the CY 2026 MA and Part D proposed rule, view the fact sheet.

Key changes proposed include:

• In recognition that obesity is a disease, the proposed rules would reinterpret coverage statute to no longer exclude anti-obesity medications for the treatment of obesity from coverage under Medicare Part D, and to require Medicaid Programs to cover these medications as well.
• Working to reform MA prior authorization (PA), utilization management, and coverage decisions. CMS data from Medicare Advantage (MA) plans indicate that, on average, MA plans overturn 8% of their decisions to deny claims when those claims are appealed to the plan; however less than 4% of denied claims are appealed in the first place. The rules will work to safeguard from the inappropriate use of Pas and internal coverage criteria and would place additional guardrails on the use of AI to protect access to health services.
• Requiring that MA organizations make their entire provider directory available to CMS for use in the Medicare Plan Finder, a tool that helps people with Medicare compare plan options, so that people with Medicare and their caregivers can search for providers more easily and compare their availability across different MA plans.
• Updating the MA and Part D Medical Loss Ratio (MLR) regulations to improve the data reported by plans.
• Expanding CMS oversight of MA advertisements to protect people from predatory behavior or misleading advertisements.

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 January 27, 2025.