Final Rule CY 2026
On April 4, 2025, CMS released the final rule CY 2026, covering Medicare Advantage (MA), Part D (Prescription Drug Plans), Medicare cost plans, and Programs of All-Inclusive Care for the Elderly (PACE). In this post, we go over some key points of the CMS final rule 2026 to keep agents up dated.
Key Provisions
- Prescriber and Prior Authorization Adjustments: MA plans can only reverse inpatient admission approvals if there’s clear evidence of fraud or error, preventing sudden post-approval denial
- Appeals Expansion: Decisions affecting appeals now apply if made during, after, or before services begin
- Insulin & Vaccine Cost-Sharing Protections: No deductible and capped cost-sharing (either less than or equal to $35 or 25% of price) for insulin; rules go live in CY 2026. Adult ACIP recommended vaccines under Part D do not charge cost-sharing or a deductible.
- Medicare Prescription Payment Plan: Monthly OOP drug payment options become standard. Automatic renewals apply unless beneficiaries opt out.
- Medicare Drug Price Negotiation Program: Pharmacies must enroll in CMS’ data Module. PDE submission timeline for selected drugs is shortened to 7 days (was originally 30).
- Medical Loss Ratio (MLR) Changes: Certain federal subsidies (selected drug subsidy, IRASA, etc.) are excluded from MA/Part D calculations
- Payment Updates: MA plan payments increased by 5.06% on average. This raises carrier reimbursement by over $25 billion. Because of late year FFS data inclusion, the effective growth rate grew to 9.04%.
- Full phase-in of medical-education cost adjustments in MA risk model
What Didn’t Make it Into the Final Rule
- Anti-obesity medication coverage remains excluded.
- No finalized rule on AI guardrails or formal health equity assessments
Implications for Medicare Agents
Plan Design and Marketing Impact
The improved payment rates and stronger benefits (e.g., capped insulin costs, free vaccines) make MA/Part D plans more attractive to beneficiaries—enhancing your ability to recommend compelling, cost-effective options.
Client Conversations and Value Messaging
You can emphasize zero cost-sharing for critical needs like adult vaccines and insulin, and promote payment flexibility via monthly prescription cost installment plans—boosting engagement with clients, especially those on tight budgets.
Administrative & Compliance Updates
- Prepare for stricter documentation requirements, especially for prescription payment plans and MLR-related tracking.
- Expect increased scrutiny on marketing practices, including proof that compensation adheres to CMS limits.
Watch a YouTube video on CMS Medicare Final Rule Proposal 2026
Compensation Boosts (Broker Commissions)
Although not part of the CMS final rule, standard compensation data from CMS shows a significant increase in 2026:
- MA Plans:
- National initial commissions rise 10.9% (e.g., from $626 to $694).
- Renewal commissions up 10.9% (e.g., $313 to $347).
- In CT, PA, DC: initial rises to $781, renewal to $391
- View a more detailed commission explanation – click here
- Part D Plans:
- Initial commissions up 4.6% ($114).
- Renewal commissions up 3.6% ($57)
- Sponsoring organizations must submit these updated commission rates to CMS and maintain payment records.
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Summary Final Rule CY 2026
Capped insulin costs, vaccine cost-sharing elimination, and flexible payment options empower agents to provide more affordable, client-focused solutions.
Higher broker commissions reward agents, but with greater compliance expectations.
Marketing oversight and fiduciary responsibility pressures are rising; agents must prioritize ethics and accuracy in representation. Agents should stay vigilant; future enforcement or reform may impact compensation and operational protocols.
Stay updated on agent events and information
As an agent, your role is stronger than ever. Stay informed, compliant, and focused on client outcomes. Although 2026 promises to be a challenge, agents who put together a good strategy and work with integrity, can thrive while supporting clients’ health and financial well-being.
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