2026 Medicare Advantage Final Rule: Regulatory Round Up & Look Ahead Under New CMS Leadership
CMS released the 2026 Medicare Advantage Final Rule on Friday, April 4, and while many policy analysts and healthcare leaders were braced for another year of sweeping changes, the updates were fairly sparse. In this blog, we’ll break down the finalized changes, deferred policy expectations, and explore what’s ahead as Dr. Mehmet Oz takes over as CMS Administrator.
Final CMS-4208-F Updates You Should Know
Although the Final Rule avoids major disruption, several minor technical and operational updates presented in the Proposed Rule were finalized. These updates signal CMS’ continued emphasis on compliance, beneficiary protections, and continued drug policy reforms.
- Inpatient Admissions Decisions: Codifies existing requirements to follow the Two-Midnight Rule and only allows plans to reopen decisions to correct obvious errors or to investigate suspected fraud. CMS says the goal of this guidance is to honor prior authorizations.
- MA Appeal Loopholes: CMS clarifies the definition of “organization determination” as plan decisions made concurrently with receipt of services. It also requires plans to notify providers of coverage determinations when requested on behalf of members. These updates are to close loopholes in existing policy and promote transparency for members who choose to appeal.
- Non-Alowable Special Supplemental Benefits for the Chronically Ill (SSBCI): Refines guardrails for SSBCI benefits to exclude certain unhealth foods, alcohol, tobacco, and life insurance.
- Risk Adjustment Data Updates: As previously proposed, minor technical updates include clarification on the definition of Hierarchical Condition Categories to broadly include International Classification of Diseases (ICD) and updates to “disease codes/groupings” to “diagnosis codes/groupings”. CMS also codified requirements for PACE organizations and cost plans to submit risk adjustment data.
- Dual Eligible Experience Enhancements: Certain Dual Eligible Special Needs Plans (D-SNP) are required to have integrated member identification cards and Health Risk Assessments (HRAs). Additionally, the Final Rule codifies timeframes for conducting HRAs and individualized care plans including enrollee or enrollee representative participation.
- Cost Sharing for Vaccines and Insulin: Effective for plan years beginning January 1, 2023, there is no cost sharing or applicable Part D deductible for adult vaccines recommended by the Advisory Committee on Immunization Practices (ACIP) covered by Part D. Regarding insulin products, Part D deductibles do not apply and beginning 20206 the cost-sharing amount for a month supply cannot exceed the lesser of either $35, 25% of the maximum fair price, or 25% of the negotiated price.
- Medicare Prescription Payment Plan: As of 2025, Part D plans must offer enrollees the option to spread out-of-pocket prescription costs into monthly payments over the plan year instead of at the pharmacy. Enrollees’ participation in this plan will automatically be renewed for the following plan year unless opted out.
Key Policies CMS Deferred for Future Rulemaking
Many of the most highly anticipated and controversial policy updates were deferred, possibly signaling a pause as new leadership takes over.
- Anti-Obesity Medications (AOMs) Coverage: Despite stakeholder and former administration support for GLP-1 coverage under Medicare Part D, CMS has not finalized any new provisions.
- Health Equity Related Proposed Rules: CMS continues to review policy updates including the Health Equity Index Reward, annual health equity analysis for UM, requirements for culturally and linguistically appropriate services, and HRAs focused on equity and Social Determinants of Health (SDOH).
- Guardrails of Artificial Intelligence: CMS acknowledges the board interest and applications of AI saying they will continue to consider appropriate future rulemaking.
Leadership Watch: Potential Changes Under Dr. Oz
With Dr. Oz now at the helm of CMS, the agency’s strategic direction could shift, especially in areas of health equity, risk adjustment, and member experience.
- De-Eemphasis of Health-Related Social Needs and Equity Policies: CMS may pull back from aggressive SDOH and equity mandates, favoring more market-driven or clinical performance approaches. Indications of this direction can be seen as a larger shift introduced in the latest Quality Rating System (Health Exchange) technical specifications which rolled back SDOH screening measures. It is critical for plans to consider how investments in these areas will continue to improve member enrollment growth and CAHPS survey results despite deregulation.
- Aggressive Pursuit of Risk Adjustment Overpayments: CMS may escalate efforts to identify and recoup risk adjustment overpayments through the revival of aggressive audit programs and refinement of data validation methodology. Plans should anticipate tighter scrutiny, increased encounter data integrity reviews, and harsher fines added under the False Claims Act.
- Member Experience Strategy: Expect potential shifts from regulatory mandates to personalized engagement approaches. Plans will likely see more policy emphasis on consumer choice, AI concierge services, remote monitoring, and digital self-management.
- Enrollment Competition: Policy leniency could appeal to broader plan designs and innovation as currently seen in the growth of C-SNPs and other tailored offerings. Enrollment flexibilities and supplemental benefit experimentation are likely to become significant competitive opportunities.
The 2026 Medicare Advantage Final Rule offers a moment of regulatory reprieve and focuses on finalizing modest technical updates while deferring more significant proposals. However, with Dr. Oz stepping into CMS leadership, healthcare leaders should prepare for potential shifts in tone and focus. The coming months are likely to bring a broad recalibration of priorities. Now is the time for leaders to double down on operational excellence and administrative savings in the face of evolving guidance and competitive opportunity.
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