CMS has issued its 2025 Final CMS Medicare Advantage Rules and the 2026 Payment Policy Updates for Medicare Advantage and Part D Programs, and Pandora Insurance has summarized these changes for agents.
What do these final rules mean for agents like you?
CMS will pay MA plans a little more than 5% more in 2026 than in 2025. What does this mean for Medicare Advntage agents like you?
Your Medicare Advantage contracted plans are getting almost double the revenue from CMS than they thought they would for 2026. You might wonder if this will help them keep benefits where they are now?
We don’t know yet, as each MA sponsor has unique cost structures that will determine whether this solves their cost issues or not. It’s probably more likely that Medicare Advantage plans with lower cost increases in 2024 may be able to keep 2025 benefits for 2026.
There is still uncertainty. We’ll keep track of this for you and let you know when we hear anything about what different MA sponsors could do for 2026 benefits.
CMS has released the 2025 Final CMS Medicare Advantage Rules.
The rules are 438 pages long and should be closely reviewed by agents. CMS breaks down its rules into 8 categories in its summary, so we’ll do the same in our summary to make it as easy to understand as possible.
- Adult Vaccines No Longer Have Any Cost-Share for Medicare Beneficiaries
CMS says adult vaccines recommended by the Advisory Committee on Immunization Practices (ACIP) are free and exempt from the Medicare Part D deductible calculations.
- The Maximum Cost for Insulin is Down to $35, with Other Cost Sharing Changes
In 2025, the Medicare Part D deductible will not apply to covered insulin products. For people not at the annual out-of-pocket maximum, their maximum copay for a 30-day supply of insulin is $35.
The formula to determine how much Medicare beneficiaries pay before reaching their annual maximum out-of-pocket amount in 2025 is the lesser of:
- $35
- 25% of the maximum fair price established under Title XI for the covered insulin product or
- 25% of the CMS negotiated price for the covered insulin product under the PDP or MA-PD plan.
- Medicare Advantage Plans and Prescription Drug Plans Must Allow Medicare Members to set Medicare Prescription Payment Plans that Cap their Cost-Sharing Under the Plan in Monthly Amounts
New rules include:
- Requirements for the Medicare Prescription Payment Plan,
- Adding several new Part D materials to be distributed,
- Making Medicare Prescription Payment Plan information required content for all Part D sponsor websites,
- Waiving the Limited Income Newly Eligible Transition (LI-NET) requirements for the Medicare Prescription Payment Plan.
It also finalized all 2026 and future-year requirements, like exempting dual-eligible special needs plans from specific requirements, requiring long-term pharmacies to inform enrollees about Medicare Prescription Payment Plans, and removing the requirement for pharmacies to tell enrollees about out-of-pocket costs under these plans when they buy prescriptions.
- Improve the Experience for Dual Eligible Enrollees on Medicare and Medicaid Managed Care Plans
CMS wants this improvement to happen by integrating the care dual-eligible enrollees receive from their Medicare and Medicaid managed care plans. They want to see policies that:
- Increase patient-centered coordination of Medicare and Medicaid services,
- Decrease shifting costs between Medicare and Medicaid plans,
- Create a seamless experience for dual-eligible individuals regardless of using a Medicare or Medicaid service.
- Have one member identification (ID) card as the ID card for both Medicare and Medicaid plans,
- Conduct a single health risk assessment (HRA) for Medicare and Medicaid for each program’s use.
There’s more to come from CMS about the amount of time these plans will have to make these changes.
- Part D Sponsors Must Quickly Submit Prescription Drug Event (PDE) Records
All MAPD and PDP plan sponsors must file their PDE event records within 30 calendar days following the date the plans or contracted entities processing claims receive the claim.
Any changes or deletions of PDE records are due within 90 calendar days of determining that they are required. Plans also have 90 days to resolve a CMS-rejected PDE record.
CMS proposes a new PDE submission timeline of 7 days for specific drugs that Part D sponsors will have to submit initial PDE records.
- Medicare Contracting Pharmacies Must Use the Medicare Negotiated Prices on Prescription Drugs
MAPD and Part D sponsors will require contracting pharmacies to honor the Medicare-negotiated prices in their contracting agreement and certify that all their drug formulary information is accurate and complete.
CMS wants all Part D enrollees and pharmacies to see the same information on drug costs and availability on MAPD and Part D prescription plans, thereby producing accurate Part D claims and payments.
- MA Members Appeals Strengthened and MA Plans Accountable for Approved Inpatient Care Stays
MA plan members and providers can easily appeal MA plan denials and decisions. Loopholes were closed, which made it hard to challenge issues when care was ongoing, and providers must be informed when coverage requests on a patient’s behalf are made.
It’s also easier for MA plans to be held accountable for inpatient stays as they can’t deny a previously approved stay. Evidence of fraud or an obvious error are the only ways MA plans can deny a previously approved inpatient stay.
This will make appeals on these care episodes easier, and CMS will monitor this aspect more closely to address problems with the MA plans.
- Risk Adjustment Data Updated to Current ICD Code Standards
Data submission requirements were also set for PACE organizations and Cost plans.
There is no coverage for GLP-1s to treat obesity, no rules regulating AI prior authorization use, and no new marketing definitions impacting agents. Provider directory requirements are still the same.
There’s a great deal to read and understand in these new rules for Medicare Advantage, and Pandora Insurance is here to help! Contact us at (305) 231-9898 to ask questions about the 2025 CMS Medicare Advantage Rules.
