The Centers for Medicare & Medicaid Services has published rules governing Medicare Advantage for the 2026 contract year, which would add significant protections for enrollees and providers. Among the most significant provisions, the rules would:
- Tighten prior authorization requirements “to remove unnecessary barriers to care stemming from the use of inappropriate prior authorization” by adding a definition of “internal coverage criteria” used in making medical necessity decisions, including prior authorization decisions. The definition includes any coverage policies that restrict access to, or payment for, medically necessary Part A or Part B services, including third party criteria. All such “internal coverage criteria” must follow recently enacted Medicare rules for their development.
- Require the prominent, public display on the Medicare Advantage organization’s website a list of all items and services for which there are benefits available under Part A or Part B where the MA organization uses internal coverage criteria when making medical necessity decisions, including prior authorization decisions.
- Prohibit a Medicare Advantage plan from post-service denial of coverage for lack of medical necessity when it had approved the service based on concurrent review, such as the concurrent review of inpatient admission.
- Require that Medicare Advantage plans’ in-network cost sharing for behavioral health benefits may be no greater than the cost sharing in Traditional Medicare for these services.
- Broaden the definition of “marketing” of Medicare Advantage plans to increase the number and type of advertisements that must be submitted to CMS for review before use in order to ensure that enrollees are not receiving misleading or incorrect information.
- Require Medicare Advantage plans to provide searchable provider directories and update any changes within 30 days.
In a press release announcing the proposed rules, HHS Secretary Xavier Becerra stated: “HHS is proposing to improve transparency, accountability, and consumer protections in Medicare Advantage…plans so that everyone receives high-quality care. To achieve that, we want to remove barriers that delay care or deny people services and medications they need to be healthy.”
The attorneys at Whatley Kallas, LLP have found that Medicare Advantage plans frequently deny their provider clients payment for medically necessary services based on the use of inappropriate criteria and that the plans have used post-service audits to deny payment for inpatient services that had been approved on concurrent review. Whatley Kallas’s attorneys are working to address these issues on behalf of their provider clients.
The proposed rules are linked here. CMS’s press release is linked here, and its fact sheet is linked here.