Starting in 2026, plans can no longer reopen or reverse approved inpatient stays unless there’s clear evidence of fraud or error. This helps ensure that once a claim is authorized, it stays that way. CMS is also closing long-standing gaps in the appeals process, requiring plans to notify both providers and patients of coverage decisions and making sure enrollees aren’t billed until a final payment decision is issued.
Stronger Protections for Admissions and Appeals
As a billing partner for independent healthcare practices, we know that policy updates can quickly impact how you operate, get paid, and support your patients.
Earlier this year, the Centers for Medicare & Medicaid Services (CMS) released the Contract Year 2026 Final Rule, modernizing the Medicare Advantage (MA) and Part D programs. The updates strengthen patient protections, improve data accuracy, and streamline how plans handle coverage decisions and prescription costs.
Here’s a quick look at what’s coming and how it may affect your billing and compliance processes.
For patients with chronic conditions, CMS added new guardrails on supplemental benefits to make sure they’re truly health-related, banning things like non-healthy food, alcohol, or life insurance. For dual-eligible members, plans will soon need to issue a single, integrated ID card and conduct a unified health-risk assessment by 2027 to make care more coordinated.
Clearer Rules for Supplemental Benefits and Dual-Eligible Plans
The rule also systemizes provisions from the Inflation Reduction Act, ensuring no cost-sharing for adult vaccines and capping insulin costs at $35 per month. Meanwhile, Part D enrollees can continue spreading their out-of-pocket drug costs over the year through the Prescription Payment Plan, which now renews automatically unless the member opts out.
At TNT, we translate complex CMS updates like these into clear, actionable steps so your billing stays compliant and stress-free. Need help preparing for 2026? Contact us today for a compliance check-in!
At TNT, we translate complex CMS updates like these into clear, actionable steps so your billing stays compliant and stress-free. Need help preparing for 2026? Contact us today for a compliance check-in!
Cost Relief Through the Inflation Reduction Act
On the technical side, CMS finalized updates to risk adjustment data for greater consistency and reinforced submission timelines for prescription drug event (PDE) records, including faster reporting for drugs under the Medicare Drug Price Negotiation Program.