CMS released its Final Rule for Medicare Advantage and PDP plans on April 4, 2025. These changes will be in effect January 1, 2026. Here are the top six things you needs to know:
1. No Cost Sharing for Adult Vaccines
$0 cost share for any adult vaccines recommended by the Advisory Committee on Immunization Practices (ACIP).
2. Insulin Cost Sharing
The cost sharing amount for a one month supply of a covered insulin product must not exceed the applicable copay amount which is $35 in 2025. In 2026 and following years the cost sharing amount will be the lesser of:
- $35
- An amount equal to 25% of the maximum fair price or
- An amount equal to 25% of the negotiated price\
3. New Requirements for Medicare Prescription Drug Payment Plan
PDP and MAPDP plans must continue to offer enrollees the option to pay their RX cost share in monthly capped payments over the course of the year through an MPPP.
Plans must:
- Automatically renew current participants in an MPPP unless they choose to opt out.
- Send the notice of voluntary termination within 10 calendar days of receipt. The effective date of termination must be within three calendar days of the voluntary termination request.
4. Simplifying the Experience for Dual Eligible Enrollees
In order to simplify access to care for D-SNP enrollees CMS has two new requirements for D-SNP’s in 2027:
- Provide enrollees with one member ID card for Medicare and Medicaid
- Provide one integrated HRA for Medicare and Medicaid instead of a separate assessment for each program.
5. Clarify MA Determinations in Order to Protect Enrollees in an Inpatient Setting
This ruling restricts an MA plans ability to reopen and modify an approved inpatient hospital decision due to additional information obtained after the approval. An approved admission can only be reopened due to an obvious error or fraud.
6. Closing MA Appeals Loopholes
This ruling will close loopholes in the appeals process that inadvertently impact providers and enrollees.
- Appeals rules will apply to adverse decisions whether the decision was made before, during or after the receipt of services.
- Plans must give both the enrollee and the provider notice of the coverage decision when the provider has submitted a request on behalf of the enrollee.
- An enrollee cannot be held liable for payment of services until a determination has been made on the providers claim for payment. This ensures the enrollee always has the right to appeal a denial.
The provisions released in the 2026 final rule only cover a handful of policies leaving quite a few proposals to be determined in the future.
Have a question? The team at PTT Financial is here to support you. Get in touch with us today.