On April 4, 2025, CMS released its Final Rule for Contract Year (CY) 2026, bringing major updates to Medicare Advantage (MA), Part D, PACE programs, and Medicare Cost Plans. The focus? Protecting enrollees, improving transparency, simplifying plan operations, and better supporting vulnerable groups—especially dual-eligible beneficiaries.

Here’s a breakdown of the most important changes agents need to know heading into 2026:

MA plans can no longer change or cancel an approved inpatient admission unless there’s clear evidence of fraud or error.

✔️ More predictability for patients and providers
✔️ Less red tape around already-approved care

CMS is tightening up the appeals process to make things clearer and fairer:

• A clearer definition of “organization determination” ensures members can appeal decisions made before, during, or after services

• Provider notification rules ensure enrollees stay informed when providers act on their behalf

• Enrollees can’t be billed until a final claim decision is made

Bottom line: Stronger protections and more transparency.

CMS has defined what can’t be offered as Special Supplemental Benefits for the Chronically Ill (SSBCI). Plans can no longer offer:

• Alcohol or tobacco
• Unhealthy food options
• Life insurance

All SSBCI must have a clear health benefit—period.

To clean up language and improve consistency, CMS is:

• Updating terms to align with ICD conventions (e.g., “diagnosis codes” and “groupings”)
• Finalizing data rules for PACE and Cost Plans

Better data = clearer reporting and fairer risk scoring.

For D-SNPs, CMS is making care easier and more integrated:

• Unified member ID cards for Medicare and Medicaid
• One health risk assessment (HRA) for both programs
• Faster care planning, with members actively involved

All changes must be implemented by 2027, but agents should start preparing now.

Some Inflation Reduction Act (IRA) provisions are now locked in:

• Vaccines: No cost-sharing for ACIP-recommended adult vaccines under Part D
• Insulin: Monthly cap in 2026 will be the lowest of:
  • $35/month
  • 25% of the drug’s maximum fair price
  • 25% of the negotiated plan price

Part D enrollees can now opt to pay their out-of-pocket (OOP) costs monthly:

• Auto-renews each year
• Flexible renewal notice timing
• Pharmacies encouraged to give verbal cost estimates

This means better budgeting for clients on expensive meds.

To support the Drug Price Negotiation Program, CMS now requires:

• 30 days to submit initial PDEs
• 90 days to correct/reject
• 7 days for selected drug claims

These changes help ensure timely, accurate pricing info.

All network pharmacies must register in the Medicare Transaction Facilitator Data Module (MTF DM). Why?

• Ensures access to negotiated prices
• Keeps claims flowing smoothly for selected drugs

These changes are designed to:

• Improve protections for your clients
• Enhance the Medicare experience
• Keep plans accountable

As an agent, staying informed helps you:

• Give better advice
• Earn client trust
• Confidently serve vulnerable populations

At Insurance Advisors Direct, we’re here to make sure you stay ahead of the curve with tools, training, and real support. Whether you’re prepping for AEP or just want to stay sharp, IAD has your back—every step of the way.

Need additional assistance, contact us today!