/ en Sat, 14 Jun 2025 12:14:25 -0500 Wed, 11 Jun 25 15:15:40 -0500 /news/headline/2025-06-11-cms-requests-comments-ma-service-level-data-collection-initial-determinations-appeals <p>The Centers for Medicare and Medicaid Services May 30 released a <a href="https://www.federalregister.gov/documents/2025/05/30/2025-09813/agency-information-collection-activities-submission-for-omb-review-comment-request" title="cms notice">notice</a> requesting comments on a proposed Medicare Advantage service level data collection  for initial determinations and appeals. The granular data will be used to enhance audit activities to ensure MA plans are operating in accordance with CMS guidelines and ensure appropriate access to covered services and benefits. CMS plans to use the information to hold MA plans accountable for their performance. Comments are due to the Office of Management and Budget by June 30. <br><br> </p> Wed, 11 Jun 2025 15:15:40 -0500 Medicare Advantage /news/headline/2025-05-30-gao-says-cms-should-target-behavioral-health-services-prior-authorization-audits <p>The Government Accountability Office May 29 released a <a href="https://www.gao.gov/products/gao-25-107342" target="_blank">report</a> recommending the Centers for Medicare & Medicaid Services target behavioral health services when auditing Medicare Advantage plans’ use of prior authorization. CMS said it currently does not target behavioral health services because they make up a small percentage of MA services, the report said.     </p><p>The report describes selected MA organizations’ prior authorization requirements and use of internal coverage criteria for prior authorization decisions on behavioral health services. It also examines CMS’ oversight of the use of internal coverage criteria, among other issues. GAO said that CMS “would take the recommendation under advisement in the future.” </p> Fri, 30 May 2025 15:23:53 -0500 Medicare Advantage /news/headline/2025-05-22-cms-expand-audits-ma-plans <p>The Centers for Medicare & Medicaid Services May 21 <a href="https://www.cms.gov/newsroom/press-releases/cms-rolls-out-aggressive-strategy-enhance-and-accelerate-medicare-advantage-audits" target="_blank">announced</a> it will immediately begin annual audits of all Medicare Advantage plans and work to clear a backlog of audits from 2018 through 2024. The audits focus on risk adjustment data validation to confirm to CMS that diagnoses submitted by Medicare Advantage plans for determining risk adjustment payments are supported by medical records. CMS expects to complete the backlog by early 2026. The agency said it will use new technology and increase its team of medical coders from 40 to approximately 2,000 to assist with efforts.</p> Thu, 22 May 2025 15:55:03 -0500 Medicare Advantage /lettercomment/2025-05-21-aha-senate-letter-supporting-improving-seniors-timely-access-care-act <div class="container"><div class="row"><div class="col-md-8"><p>May 21, 2025</p><div class="row"><div class="col-md-6"><p>The Honorable Roger Marshall, M.D.<br>United States Senate<br>479A Russell Senate Office Building<br>Washington, DC 20510</p></div><div class="col-md-6"><p>The Honorable Mark Warner<br>United States Senate<br>703 Hart Senate Office Building<br>Washington, DC 20510</p></div></div><p>Dear Senators Marshall and Warner:</p><p>On behalf of our nearly 5,000 member hospitals, health systems and other health care organizations, our clinician partners — including more than 270,000 affiliated physicians, 2 million nurses and other caregivers — and the 43,000 health care leaders who belong to our professional membership groups, the ���������� Association (AHA) is pleased to support your legislation, the Improving Seniors’ Timely Access to Care Act.</p><p>Inefficient prior authorization requirements are a pervasive problem among certain plans in the Medicare Advantage (MA) program that result in delays in care and add financial burden and strain to the health care system. Your bipartisan legislation would address these issues through streamlining prior authorization requirements under MA plans by eliminating complexity and promoting uniformity that would reduce the wide variation in prior authorization methods that frustrate both patients and providers.</p><p>Specifically, your bill would establish an electronic prior authorization standard to streamline approvals, reduce the time a health plan is allowed to consider a prior authorization request, require MA plans to report on their use of prior authorization, including the use of artificial intelligence in prior authorization and the rate of approvals and denials, and encourage MA plans to adopt policies that adhere to evidence-based guidelines.</p><p>Thank you for your support in improving the prior authorization process to increase patient access to care and reduce the burden for providers. We look forward to continuing to work with you on this issue and urge Congress to pass this bill to ensure all Medicare beneficiaries have access to timely and appropriate care.</p><p>Sincerely,<br>/s/<br>Stacey Hughes<br>Executive Vice President</p></div><div class="col-md-4"><div class="external-link spacer"><a class="btn btn-wide btn-primary" href="/system/files/media/file/2025/05/aha-senate-letter-supporting-improving-seniors-timely-access-to-care-act-5-21-2025.pdf" target="_blank" title="Click here to download the AHA Senate Letter Supporting Improving Seniors’ Timely Access to Care Act PDF.">Download the Letter PDF</a></div></div></div></div> Wed, 21 May 2025 14:01:38 -0500 Medicare Advantage /lettercomment/2025-05-21-aha-house-letter-supporting-improving-seniors-timely-access-care-act <div class="container"><div class="row"><div class="col-md-8"><p>May 21, 2025</p><div class="row"><div class="col-md-6"><p>The Honorable Mike Kelly<br>U.S. House of Representatives<br>1707 Longworth House Office Building<br>Washington, DC 20515</p></div><div class="col-md-6"><p>The Honorable Ami Bera, M.D.<br>U.S. House of Representatives<br>172 Cannon House Office Building<br>Washington, DC 20515</p></div></div><div class="row"><div class="col-md-6"><p>The Honorable Suzan DelBene<br>U.S. House of Representatives<br>2311 Rayburn House Office Building<br>Washington, DC 20515</p></div><div class="col-md-6"><p>The Honorable John Joyce, M.D.<br>U.S. House of Representatives<br>2102 Rayburn House Office Building<br>Washington, DC 20515</p></div></div><p>Dear Representatives Kelly, DelBene, Bera and Joyce:</p><p>On behalf of our nearly 5,000 member hospitals, health systems and other health care organizations, our clinician partners — including more than 270,000 affiliated physicians, 2 million nurses and other caregivers — and the 43,000 health care leaders who belong to our professional membership groups, the ���������� Association (AHA) is pleased to support your legislation, the Improving Seniors’ Timely Access to Care Act.</p><p>Inefficient prior authorization requirements are a pervasive problem among certain plans in the Medicare Advantage (MA) program that result in delays in care and add financial burden and strain to the health care system. Your bipartisan legislation would address these issues through streamlining prior authorization requirements under MA plans by eliminating complexity and promoting uniformity that would reduce the wide variation in prior authorization methods that frustrate both patients and providers.</p><p>Specifically, your bill would establish an electronic prior authorization standard to streamline approvals, reduce the time a health plan is allowed to consider a prior authorization request, require MA plans to report on their use of prior authorization, including the use of artificial intelligence in prior authorization and the rate of approvals and denials, and encourage MA plans to adopt policies that adhere to evidence-based guidelines.</p><p>Thank you for your support in improving the prior authorization process to increase patient access to care and reduce the burden for providers. We look forward to continuing to work with you on this issue and urge Congress to pass this bill to ensure all Medicare beneficiaries have access to timely and appropriate care.<br> </p><p>Sincerely,<br>/s/<br>Stacey Hughes<br>Executive Vice President</p></div><div class="col-md-4"><div class="external-link spacer"><a class="btn btn-wide btn-primary" href="/system/files/media/file/2025/05/aha-house-letter-supporting-improving-seniors-timely-access-to-care-act-5-21-2025.pdf" target="_blank" title="Click her to download the AHA House Letter Supporting Improving Seniors’ Timely Access to Care Act PDF.">Download the Letter PDF</a></div></div></div></div> Wed, 21 May 2025 13:05:17 -0500 Medicare Advantage /news/headline/2025-05-05-cms-leaders-share-insights-deregulation-medicare-advantage-oversight <p>Leaders from the Centers for Medicare & Medicaid Services at the 2025 AHA Annual Membership Meeting May 5 discussed issues on the agency’s agenda in a fireside chat moderated by Ashley Thompson, AHA senior vice president, public policy analysis and development. Stephanie Carlton, CMS deputy administrator and chief of staff, and John Brooks, CMS deputy administrator and chief policy and regulatory officer, discussed regulatory burden and oversight of commercial health insurance plans, among other topics.</p><p>Brooks discussed the challenges imposed on hospitals and health systems when faced with new regulatory requirements annually.</p><p>“It’s really critical to stop, take stock and assess the cumulative weight on all those regulations on industry,” he said. “We need to look across the board, whether it’s claims administration, requirements around Conditions of Participation or quality of measurement.”</p><p>The officials also discussed Medicare Advantage and oversight of commercial health plans, stressing the need for prior authorization policies to work efficiently and not become used as a tool to deny care and place a burden on providers.</p><p>“It’s not supposed to be the tool itself to prevent care from being given, and I think we’ve seen that happen in a lot of cases,” Brooks said. “So I think that’s an area where we definitely plan to spend some time over the next year or two to try and figure out.”</p><p>Carlton discussed value-based care and its potential for growth, particularly in rural areas.</p><p>“Rural access is really important to us, and I think there’s an important way to think creatively about models that will work in rural areas,” she said. “Obviously, access in different places is critical, but [we need to] think about how do we do that and how do we work with smaller sites.”</p> Mon, 05 May 2025 16:46:29 -0500 Medicare Advantage /news/headline/2025-04-30-report-hospitals-and-health-systems-squeezed-persistent-economic-challenges <p>The AHA April 30 released a <a href="/costsofcaring">report</a> highlighting how hospitals and health systems continue to experience significant financial headwinds that can challenge their ability to provide care to their patients and communities. The report outlines the financial burden of heightened expenses hospitals have faced in recent years in caring for patients, as well as the increasing strain on the field.  <br> <br>It explains how hospitals have raised wages to recruit and retain staff amid workforce shortages and how Medicare and Medicaid continue to underpay hospitals for patient care as shortfalls worsen. Other findings include how practices of certain Medicare Advantage plans exacerbate hospitals’ financial burden, and that tariffs on medical imports could significantly raise costs for hospitals as nearly 70% of medical devices marketed in the U.S. are manufactured exclusively overseas. <br><br>“This report should serve as an alarm bell that a perfect storm of rising costs, inadequate reimbursement, and certain corporate insurer practices are jeopardizing the ability of hospitals to deliver high-quality, timely care to their communities,” <a href="/press-releases/2025-04-30-new-aha-report-hospitals-and-health-systems-squeezed-persistent-economic-challenges">said</a> AHA President and CEO Rick Pollack. “With so much at stake, policymakers must recommit to making preserving access to hospital care a national priority.” </p> Wed, 30 Apr 2025 14:52:51 -0500 Medicare Advantage <div class="container"><div class="row"><div class="col-md-8"><p>CMS has released an <a href="/system/files/media/file/2025/04/medicare-advantage-provider-complaint-submission-form-2025.pdf" target="_blank" title="Updated Complaint Form">updated complaint</a> form with instructions for Medicare providers seeking assistance from the Centers for Medicare & Medicaid Services (CMS) in resolving Medicare Advantage (MA) claims issues. The complaint form is a cover sheet that must generally be submitted to CMS in a password-protected file, along with the requested documentation as indicated on the form, to the CMS Drug and Health Plan Operations (DHPO) email at <a href="mailto:MedicarePartCDQuestions@cms.hhs.gov" target="_blank" title="CMS Drug and Health Plan Operations email">MedicarePartCDQuestions@cms.hhs.gov</a>.</p><p>CMS updated the complaint form to direct Medicare providers with quality-related complaints to submit those complaints to the Center for Clinical Standards and Quality (CCSQ) email at <a href="mailto:BFCCQIOConcerns@cms.hhs.gov" target="_blank" title="Center for Clinical Standards and Quality email">BFCCQIOConcerns@cms.hhs.gov</a>.</p><p>While CMS allocates its oversight of the MA program across the agency’s<a href="https://www.cms.gov/about-cms/where-we-are/regional-offices" target="_blank" title="CMS regional offices"> regional offices</a>, the agency receives and processes all MA inquiries and complaints from providers through centralized email inboxes. This process replaced the former process of contacting CMS’ regional emails for MA complaints and questions.</p><p>For CMS to act upon cases submitted through the centralized email, the provider must include all information and documentation requested on the cover sheet; refrain from providing additional documentation not listed on the cover sheet (such as medical records); and certify that an effort has been made to resolve the issue with the MA plan directly prior to contacting CMS.</p><p>CMS specifies that upon receipt of a complaint, CMS staff will input appropriate cases into the agency’s Complaint Tracking Module and respond back to the provider organization with a complaint ID for reference. While CMS reminds providers that its role is not to determine medical necessity or payment amounts for disputed cases, the agency will seek to identify trends in provider complaints to investigate and address broader issues with MA plans where appropriate.</p><p>The complaint form cover sheet provides additional information to providers about the types of appeal complaints and claims payment disputes that can be submitted using this form, as well as technical specifications for documentation submission requirements.</p><p>In addition to the DHPO email, hospitals and health systems may send complaints about inappropriate utilization management criteria or claims processing approaches that they believe do not comply with CMS requirements to the CMS Part C and D Audit email at <a href="mailto:part_c_part_d_audit@cms.hhs.gov" target="_blank" title="CMS part 3 and part d audit email">part_c_part_d_audit@cms.hhs.gov</a>. This may include practices related to prior authorization, concurrent review, or retrospective review to deny or downgrade coverage or payment that the provider believes is not permitted under CMS rules. These types of complaints can be submitted to both the Part C and D Audit email and the DHPO email. Note there is no cover sheet or form required for the Part C and D Audit email.  </p><h2>AHA TAKE</h2><p>The AHA continues to be concerned about certain MA plan policies that inappropriately restrict or delay patient access to care. The AHA continues to urge CMS to increase oversight and enforcement to address continued gaps in compliance among certain MA plans.</p><p>The establishment of a streamlined provider complaint and inquiry pathway has been a core part of our advocacy effort to ensure that providers can raise suspected violations of federal rules to federal regulators independent of contractual dispute resolution mechanisms. We applaud CMS’ efforts to create a distinct pathway for providers to submit quality-related complaints and appreciate the agency’s continued efforts to improve the Medicare program.</p><h2>FURTHER QUESTIONS</h2><p>If you have further questions, please contact Noah Isserman, AHA’s director of health insurance and coverage policy, at <a href="mailto:nisserman@aha.org" target="_blank" title="Noah Isserman email">nisserman@aha.org</a>.<br><br></p></div><div class="col-md-4"><a href="/system/files/media/file/2025/04/updated-medicare-advantage-question-and-complaint-process-for-provider-organizations-advisory-4-25-2025.pdf"><img src="/sites/default/files/inline-images/cover-updated-medicare-advantage-question-and-complaint-process-for-provider-organizations-advisory-4-25-2025.png" data-entity-uuid data-entity-type="file" alt="Member Advisory: Updated Medicare Advantage Question and Complaint Process for Provider Organizations PDF" width="691" height="894"></a></div></div></div> Fri, 25 Apr 2025 15:03:34 -0500 Medicare Advantage <div class="container"><div class="row"><div class="col-md-8"><p>The Centers for Medicare & Medicaid Services (CMS) earlier this month released its <a href="https://www.cms.gov/newsroom/press-releases/cms-finalizes-2026-payment-policy-updates-medicare-advantage-and-part-d-programs" target="_blank">rate announcement</a> and <a href="https://www.federalregister.gov/public-inspection/2025-06008/medicare-and-medicaid-programs-contract-year-2026-policy-and-technical-changes-to-the-medicare" target="_blank">final rule</a> on Policy and Technical Changes to the Medicare Advantage, Medicare Prescription Drug Benefit Program, Medicare Cost Plan Program, and Programs of All-Inclusive Care for the Elderly for contract year (CY) 2026. The rule confirms prior rulemaking regarding MA plan prior authorization determinations and strengthens provider and patient access to appeals processes related to concurrent medical reviews.</p><p>However, the agency did not finalize a number of proposals and deferred others. Specifically, the final rule declines to finalize proposals related to health equity analysis on plan utilization management programs, guardrails on plan use of artificial intelligence in coverage determinations, and coverage for anti-obesity medications. The agency deferred action until future rulemaking on the following proposals: </p><ul><li>Enhanced rules on internal coverage criteria<strong>.</strong></li><li>Additional Medicare Advantage Organizations (MAOs) marketing and communications controls.</li><li>Increased transparency requirements regarding MAO provider directories.</li><li>Behavioral health cost-sharing requirements.</li><li>Revised MAO medical loss ratio reporting and auditing processes.</li></ul><p>Overall, the agency increases payments to MAOs on average by 5.06% from 2025 to 2026. This is an increase of 2.83 percentage points since the CY 2026 Advance Notice, largely attributable to an increase in the effective growth rate, reflecting fee-for-service Medicare spending.</p><h2>AHA TAKE</h2><p>The AHA appreciates that CMS finalized changes to organizational determinations and appeal rights, which support greater transparency around health plan downgrades of the level of care, as well as reaffirmed its policies on prior authorizations. These important provisions will help safeguard Medicare Advantage (MA) enrollees’ ability to access medically necessary care. Simultaneously, the AHA looks forward to working with the administration to further advance policies that increase oversight of MA plans, and in particular, supports efforts to better ensure that all Medicare beneficiaries receive the same access to care, whether they are enrolled in an MAO or Traditional Medicare.</p><p>For additional detail, the CMS fact sheets on the <a href="https://www.cms.gov/newsroom/fact-sheets/2026-medicare-advantage-and-part-d-rate-announcement" target="_blank">rate announcement</a> and <a href="https://www.cms.gov/newsroom/fact-sheets/contract-year-2026-policy-and-technical-changes-medicare-advantage-program-medicare-prescription-final" target="_blank">policy and technical changes rule</a> summarize key provisions.</p><h2>HIGHLIGHTS OF THE FINAL RULE</h2><p><strong>Organization Determinations and Appeal Rights</strong></p><p>CMS finalizes proposals to strengthen existing regulations regarding MA coverage and responsibility to provide all reasonable and necessary Medicare Parts A and B benefits. These include:</p><ul><li>Clarifying that an enrollee’s further liability to pay for services cannot be determined until an MAO has made a determination on a request for payment.</li><li>Modifying the definition of an organization determination to clarify that a coverage decision made by an MAO contemporaneously to when an enrollee is receiving such services, including level of care decisions (such as inpatient or outpatient coverage), is an organization determination subject to appeal and other existing requirements.</li><li>Finalizing a proposal to strengthen the notice requirements to ensure that a provider who has made a standard organization determination request on an enrollee’s behalf, or when it was otherwise appropriate, receives notice of the MAO’s decision.</li></ul><p><strong>Honoring Prior Authorizations and Concurrent Medical Necessity Determinations</strong></p><p>The final rule reinforces existing CMS policy that requires plans to adhere to medical necessity decisions rendered during a prior authorization process. The rule establishes that plans may only reconsider a previously approved prior authorization determination for obvious error or fraud. Additionally, as noted above, the rule explicitly extends this protection to concurrent determinations made pursuant to inpatient admissions.</p><p><strong>Medicare Prescription Payment Plan</strong></p><p>In the final rule, CMS reiterates its requirement under the Inflation Reduction Act of 2022 (IRA) to establish a payment plan that would allow enrollees in Medicare Part D and MA plans with prescription drug coverage the ability to pay for their out-of-pocket drug costs monthly instead of requiring a single upfront payment. This option must be made available for Medicare Part D enrollees and those individuals enrolled in MA plans with prescription drug coverage beginning Jan. 1, 2025.</p><p><strong>Other Pharmacy-related Provisions</strong></p><p>The final rule includes several additional pharmacy-related provisions, such as:</p><ul><li>Requiring that Part D sponsors’ network contracts with pharmacies mandate such pharmacies to be enrolled in the Medicare Drug Price Negotiation Program’s Medicare Transaction Facilitator Data Module.</li><li>Codifying provisions of the IRA that stipulate there is no cost-sharing or applicable deductible for an adult vaccine recommended by the Advisory Committee on Immunization Practices covered under Part D.</li><li>Codifying provisions of the IRA that stipulate the Part D cost-sharing amount for a one-month supply of covered insulin products must not exceed the proposed “covered insulin product applicable cost-sharing amount” and must not be subject to the Part D deductible.</li></ul><h2>POLICIES THAT THE AGENCY DID NOT FINALIZE</h2><p><strong>Coverage of Anti-obesity Medications</strong></p><p>CMS does not move forward with a proposal to allow the coverage of anti-obesity medications that are indicated to reduce excess body weight and maintain long-term weight reduction in individuals who have been diagnosed with obesity. This regulation would have applied to such drugs covered under both Medicare Part D and Medicaid.</p><p><strong>Guardrails for Artificial Intelligence</strong></p><p>The agency does not adopt proposed guardrails for MAO utilization of artificial intelligence (AI) in coverage determinations. The proposal sought to ensure that MAOs continue to provide equitable access to services, irrespective of technological advances, by updating existing regulations to account for the use of AI and other automated systems. This includes clarifications that MAOs' use of AI or automated systems must comply with existing laws and regulations that prohibit discrimination against beneficiaries based on any factor related to health status or condition. Despite not finalizing the specific guardrails, the agency notes that AI usage remains important and will be the subject of future agency actions.</p><p><strong>Annual Health Equity Analysis of Utilization Management Policies</strong></p><p>The rule explicitly does not finalize proposed changes that would have required MAO utilization management committees to conduct an annual health equity analysis of plan prior authorization usage by examining more granular data on specified metrics, such as the percentage of requests that were approved and the median amount of time plans spent in issuing a determination on prior authorization requests. As a result, the 2025 policies remain unchanged, which require such analyses to be conducted on aggregate data.</p><h2>POLICIES DEFERRED FOR FUTURE RULEMAKING</h2><p><strong>MA Plan Utilization of Internal Coverage Criteria for Making Coverage Decisions</strong></p><p>CMS defers a proposal that sought to clarify that all criteria not found within the CMS coverage determination rules were considered “internal” and were subject to applicable regulations. Additionally, the proposal would have created specific limitations on when plans could utilize internal criteria and specifically prohibited criteria that failed to provide a clinical benefit to the patient.   </p><p><strong>Provider Directory Requirements and Inclusion in Medicare Plan Finder</strong></p><p>CMS defers a proposal to improve MAO provider directories for future rulemaking. The previous proposal would have required MA plans to report provider directory data to CMS for incorporation into the agency’s Medicare Plan Finder platform — an online resource designed to aid enrollees in selecting Medicare coverage. Furthermore, the rule would have required MAOs to attest to the accuracy of provider directory information. The agency also sought stakeholder input on the frequency with which plans should be required to attest to such accuracy, recognizing that provider directory and network information are subject to frequent updates and changes.</p><p><strong>Cost-sharing for Behavioral Health Services</strong></p><p>CMS defers for future rulemaking a proposal to improve access to behavioral health for enrollees by ensuring that in-network cost-sharing for behavioral health services is no greater than cost-sharing for those services in Traditional Medicare. When CMS proposed the changes to cost sharing for behavioral health services, the agency sought stakeholder comment on applying a possible transition period to implement the proposed cost-sharing standard for certain benefits.</p><p><strong>Marketing and Oversight of Agent and Broker Activity</strong></p><p>CMS defers a proposal to add new requirements and oversight for MA agents and brokers for future rulemaking. The proposal sought to protect consumers from inappropriate, confusing or misleading marketing or communication materials.</p><p><strong>Medical Loss Ratio Reporting Requirements</strong></p><p>The final rule did not address proposed revisions to MA and Part D plan medical loss ratio (MLR) calculations. The proposed rule included a provision that, if finalized, would have required plans to submit detailed information on how a plan calculated the MLR, established additional restrictions on plan reporting of “quality improvement activities,” and established an MA MLR auditing process.  </p><p><strong>Administration of Supplemental Benefits with Debit Cards</strong></p><p>CMS does not address the proposed new requirements governing the proper administration of supplemental benefits provided to enrollees through debit cards.</p><h2>HIGHLIGHTS OF THE RATE ANNOUNCEMENT</h2><p><strong>Payments to MAOs</strong></p><p>Payments to MAOs will increase on average by 5.06% from 2025 to 2026. A significant component of the rate increase was driven by the effective growth rate — or increase in spending in Traditional Medicare, which was calculated at 9.04%. CMS estimates that the rate increase will mean an additional $25 billion in MA payments to MAOs in CY 2026.   </p><p><strong>Removal of Medical Education Costs</strong></p><p>CMS finalizes, as proposed, the completion in CY 2026 of a three-year phase-in of a technical adjustment removing medical education costs from the historical and projected expenditures supporting the FFS costs included in the growth rate calculations. For CY 2026, CMS will apply 100% of the adjustment for MA-related medical education costs.</p><p><strong>Phase-in of Risk Adjustment Model Changes</strong></p><p>In 2026, CMS will complete a three-year phase-in of improvements to the MA risk adjustment model that was finalized in the CY 2024 Rate Announcement. The changes to the MA risk adjustment model include a reduction in the number of diagnosis codes included and changes in the weights of Hierarchical Condition Category demographic elements. CMS previously stated that the revised model will ensure risk adjustment payments better reflect the cost of care for beneficiaries and make the model less susceptible to discretionary coding on the part of corporate commercial plans.</p><h2>FURTHER QUESTIONS</h2><p>If you have further questions, please contact Noah Isserman, AHA’s director of health insurance and coverage policy, at <a href="mailto:nisserman@aha.org">nisserman@aha.org</a> or Terry Cunningham, AHA’s senior director of administrative simplification policy, at <a href="mailto:tcunningham@aha.org">tcunningham@aha.org</a>.</p></div><div class="col-md-4"><a href="/system/files/media/file/2025/04/cms-issues-rate-announcement-and-final-rule-for-cy-2026-medicare-advantage-prescription-drug-plans-4-15-2025.pdf"><img src="/sites/default/files/2025-04/cover-cms-issues-rate-announcement-and-final-rule-for-cy-2026-medicare-advantage-prescription-drug-plans-advisory-4-15-2025-r.png" data-entity-uuid data-entity-type="file" alt="Cover Image of CMS Issues Rate Announcement and Final Rule for CY 2026 Medicare Advantage, Prescription Drug Plans Advisory" width="640" height="828"></a></div></div></div> Tue, 15 Apr 2025 12:17:47 -0500 Medicare Advantage /news/news/2025-04-07-cms-finalizes-cy-2026-medicare-advantage-part-d-rates <p>The Centers for Medicare & Medicaid Services April 7 <a href="https://www.cms.gov/newsroom/press-releases/cms-finalizes-2026-payment-policy-updates-medicare-advantage-and-part-d-programs" target="_blank">released</a> finalized payment rates for calendar year 2026 Medicare Advantage and Part D plans. Payments to MA plans are projected to result in an increase of 5.06%, or more than $25 billion. This is an increase of 2.83% since the CY 2026 Advance Notice, which CMS attributes to an increase in the effective growth rate. The AHA is continuing to review the rate announcement and recent <a href="/news/headline/2025-04-04-cms-releases-final-rule-2026-medicare-advantage-prescription-drug-plans" target="_blank">policy rule</a> and will provide members with more information soon.</p> Mon, 07 Apr 2025 18:20:15 -0500 Medicare Advantage