April 9, 2025
On April 4, the Centers for Medicare & Medicaid Services (CMS) finalized the 2026 MA Policy and Technical Changes rule. Of note, CMS is not finalizing certain provisions from the proposed rule, most importantly the proposal requiring coverage of anti-obesity medications (AOMs) in both Medicare and Medicaid. CMS said that it may address these proposals in future rulemaking, as appropriate, after more review of the drugs’ potential benefits and relevant costs, including costs to state Medicaid agencies.
Cigna urged CMS to withdraw this proposal, along with AHIP and industry partners, and explore legislative changes to the statutory prohibition on Medicare coverage of AOMs with Congress. We noted significant concerns that CMS must address before considering such an impactful change, including permitting conditions of coverage that align with current clinical practice and evidence-based guidelines, how CMS will monitor and address supply chain shortages, and how Star Ratings would be impacted.
Among other policies, CMS finalized limitations on Medicare Advantage (MA) plans’ ability to change approved inpatient admission decisions; a fix for a series of MA appeals process “loopholes”; risk adjustment changes as outlined in the proposed rule; and codified Inflation Reduction Act (IRA) provisions such as vaccine cost-sharing, insulin cost-sharing, and the Medicare Prescription Payment Plan.
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