The Centers for Medicare & Medicaid Services (CMS) released the Contract Year 2026 Medicare Advantage (MA) and Medicare Part D Policy and Technical Changes proposed rule (PDF) on Nov. 26.
Most notable of the proposals is the coverage of GLP-1 weight loss drugs. Historically, the CMS has excluded coverage for anti-obesity medications, but under this proposal, the agency would recognize obesity as a distinct disease and reinterpret the statute to permit coverage of GPL-1s under Part D and Medicaid plans when used for weight loss for the treatment of obesity. The CMS estimates that approximately 7% of the Part D population and 12% of the adult Medicaid population would become eligible for GPL-1s. If finalized, the CMS noted that this would result in an estimated $24.8 billion increase in trust fund expenditures for Medicare and a $14.8 billion increase in Medicaid expenditures over a ten-year period.
The proposed rule also builds on prior authorization policies by proposing to clarify definitions for internal coverage criteria, collect additional data, and increase transparency. Similarly, related to prior authorization, the CMS is proposing to require MA plans ensure services are provided equitably whether from human or automated systems, as well as requiring plans to comply with antidiscrimination laws when utilizing artificial intelligence tools. Additional proposals include new standards for MA medical loss ratio reporting to better align with Medicaid and commercial requirements, expansion of the definition of marketing related to MA and Part D plans, requirements for the Medicare Plan Finder to include searchable provider directories for MA plans, clarification on the use of debit cards as a supplemental benefit, and limiting beneficiary cost sharing for behavioral health benefits to be no greater than traditional Medicare.
Comments are due Jan. 27, 2025.