On April 4th, CMS released the Medicare Advantage (MA) final rule for CY 2026. The final rule limits the ability of MA plans to reopen or modify a previously approved prior authorization for inpatient admission, limiting them to reopen cases only in the event of “obvious fraud or error.” The rule also closes a loophole that MA plans had been using to downgrade patients from Inpatient to Observation status. In compliance with the Inflation Reduction Act, the rule codified requirements to eliminate cost-sharing for adult vaccines recommended by the Advisory Committee on Immunization Practices and covered under Medicare Part D.  

CMS announced a name change for the Health Equity Index reward, set to take effect for the 2027 Star ratings. It will now be known as the Excellent Outcomes for All (EO4all) reward. Starting on page 75 of the rule, CMS also lists supplemental benefits that will no longer be approved. This includes non-healthy food, hospital indemnity insurance and broad membership-type programs. 

There were a number of items from the proposed rule that were eliminated to allow the Trump Administration more time to assess; for example, the rule didn’t finalize guardrails for the use of Artificial Intelligence or coverage of GLP-1 weight-loss drugs.