The 2026 Final Rule, released by CMS in April 2025, brings meaningful changes to Medicare Advantage (MA), Part D, and Special Needs Plans (SNPs). These updates aim to improve transparency, enhance care for high-needs populations, and modernize how payments are made to insurers. As a Medicare agent, staying informed helps you guide clients accurately and position your sales strategy for success
Key Changes Agents Should Know
1. Medicare Advantage Plan Payment Increase
CMS approved a 5.06% increase in average plan payments for 2026. This is expected to give insurers more room to offer richer benefits, reduce premiums, or expand supplemental services. Once the carriers release the 2026 plan designs, we will see if they have added enhancements.
2. Prescription Drug Reforms (Part D)
- Insulin Copays Capped: $35/month or 25% of the negotiated price; whichever is less.
- Vaccines: ACIP-recommended vaccines remain free (no deductible or cost-sharing).
- Prescription Payment Plan: Beneficiaries can spread out drug cost payments over the year.
- New guidelines clarify enrollment, pharmacy coordination, and billing practices.
Agents; educate clients on enrolling in the payment plan; especially those with high drug costs.
3. Risk Adjustment Overhaul – Accuracy Takes Priority
CMS is completing its transition to the 2024 CMS-HCC risk adjustment model, which will be 100% in effect for 2026 MA plan payments. This model better reflects today’s healthcare needs by using updated diagnosis groupings and more current data.
Why It Matters:
- Plans with more chronically ill members (diabetes, COPD, heart failure) get higher CMS payments.
- Plans with healthier enrollees receive less.
Impact on Agents:
- Some plans may adjust benefits or premiums in response to expected payment changes.
- You may see enhanced offerings from plans that excel in care coordination and documentation.
- SNPs and plans serving dual-eligibles may experience meaningful shifts; pay attention to service area changes or new plan launches.
Bottom Line: This makes the system more fair, but you should monitor plan benefit designs closely in your key markets
Agents if you are ready to join the Crowe team, click here for online contracting.
4. D-SNP Simplification (Effective 2027)
CMS is improving integration for dual-eligible members with:
- One Medicare-Medicaid ID card
- Unified Health Risk Assessment (HRA)
- Faster HRA and care plan timelines
These changes make D-SNPs easier to explain and more attractive to clients. Prepare now by understanding how your D-SNP partners are adapting.
5. Inpatient Coverage Notification Rules
Plans must now notify both providers and beneficiaries at the same time about inpatient coverage decisions—helping ensure clear, real-time communication during hospital stays.
Watch a quick YouTube video on the Medicare 2026 Final Rule Proposal
6. What Didn’t Make the Cut
CMS did not finalize several proposed changes:
- No Part D coverage for anti-obesity drugs
- No new broker commission rules
- No restrictions on agent marketing or AI guardrails (yet)
Important: CMS has hinted that more agent-related changes may be proposed in the near future. Stay vigilant!
Updated 2026 Agent Commission Rates
CMS has announced significant increases in maximum allowable broker commissions for Medicare Advantage and Part D for Contract Year 2026 representing the largest MA commission bump in years
Click here for all the details
Action Steps for Agents
- Study how your top plans may adjust benefits due to new risk adjustment payments.
- Help clients understand the Prescription Payment Plan and insulin savings.
- Stay tuned for more changes, especially around marketing, commissions, and AI regulations.
- Start preparing D-SNP marketing materials ahead of the 2027 simplification rollout.
Find out about all the latest events and information for agents
Summary: CMS Final Rule 2026
| Topic | Key Takeaway |
|---|---|
| MA Plan Payments | 5.06% average increase—possible richer benefits or lower premiums |
| Part D Drug Costs | $35 insulin cap, free ACIP vaccines, new drug payment installment option |
| Risk Adjustment Model | 100% switch to 2024 CMS-HCC model—better data, more fairness |
| D-SNP Integration (2027) | One card, combined HRA, faster care plan delivery |
| Inpatient Notifications | Providers & beneficiaries notified simultaneously |
| Not Included | No commission changes, obesity drug coverage, or AI rules (yet) |
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