Payers face numerous challenges in the Medicare Advantage space. These include lower than average rate increases and post pandemic utilization spikes that put pressure on margins and operations. The AHA appreciates the steps taken by CMS to strengthen oversight of Medicare Advantage plans 2026 that could potentially harm patients by restricting their access to medically necessary care. However, the organization remains concerned about the lack of publicly available data and the ability for MA organizations to mask disparities by aggregating coverage criteria metrics.
To cope with these pressures, some payers may consider trimming or removing some benefits from their plans. However, this could have significant impacts on members’ access to care.
Supplemental Benefits Notices
Starting in 2026, MA plans will send a personalized notice to enrollees between June 30th and July 31st listing any supplemental benefits that were not used during the first 6 months of the year. This will help ensure that supplemental benefits are being utilized to their full potential, and help individuals make informed enrollment decisions.
The rule also promotes access to behavioral health services by limiting MA plan cost sharing for services provided by mental health and substance use disorder counselors who meet the statutory definition of counseling or therapy providers, and by clarifying provider directory information and improving Medicare Plan Finder’s functionality. It also proposes new policies to limit barriers to care caused by inappropriate prior authorization, and updates requirements for the RADV process.
In addition, the rule enhances CMS oversight of agent and broker marketing and communication materials to ensure they are discussing important topics with individuals before they select a Medicare Advantage plan. This includes the coverage and costs of an individual’s providers, pharmacies, prescription drug plans, and supplemental benefit options.
Out-of-Network Fee-For-Service (FFS) Providers
To better manage costs and improve outcomes, payers should focus on rationalizing their supplemental benefit portfolios, focusing on the benefits members use most. Moreover, they should evolve their product offerings and messaging to meet changing member preferences, including addressing social determinants of health (SDoH) needs and closing gaps in clinical care.
Payers can also take steps to increase efficiency by leveraging upcoming Medicare Advantage 2026 changes, such as new details on supplemental benefit spending and additional requirements for cost reporting. These new requirements will require plans to report data at the contract level rather than just at the plan-level, and will allow KFF to examine supplemental benefit spending more closely.
Additionally, CMS’s new monthly integrated-care SEP will give dual eligibles the opportunity to make a lateral move between fully or highly aligned D-SNPs on a monthly basis. This will allow them to avoid a quarterly SEP and avoid having to wait until AEP to change plans like they had in the past.
Transparency
The agency also proposes changes to the requirements for agents and brokers to discuss important information with individuals before enrolling them in a Medicare Advantage plan. This includes the requirement that a broker discuss an individual’s providers, pharmacies, prescription drug coverage and costs, and premiums.
The proposal would expand this requirement to include the cost of an individual’s plan’s deductible, copays and other out-of-pocket costs. It also expands the information a plan must provide to an individual when a plan makes an adjustment to their enrolled OOP balance. This change is intended to align with the new requirements finalized in 2024’s Payment Notice for EDGE and HHS-RADV.
Personalized Notices
As the Medicare Advantage market continues to evolve, payers need to ensure that their marketing and enrollment efforts remain compliant with CMS rules. Payers should also consider ways to leverage the member experience in their efforts to lower costs. Better coordinated, accessible care can lead to more efficient health outcomes and cost reductions for Medicare Advantage members.
Starting in 2026, full-benefit dually eligible individuals will no longer be able to switch their Medicare Advantage plan on a quarterly basis. Instead, they will only be able to do so during the Medicare Advantage open enrollment period, an initial enrollment period, or one of the other Medicare Advantage SEP options available.
We are also proposing to strengthen the agency’s oversight of agents and brokers to help individuals make fully informed decisions when choosing a Medicare Advantage plan. This includes requiring agents and brokers to discuss specific topics before enrolling individuals into a Medicare Advantage plan, including information on their providers, pharmacies, and prescription drug coverage and costs.