2026 CMS Final Rule
The Centers for Medicare & Medicaid Services (CMS) has released its final rule for Contract Year 2026, bringing significant updates to Medicare Advantage (Part C), Medicare Prescription Drug (Part D), Medicare Cost Plan, and Programs of All-Inclusive Care for the Elderly (PACE). This rule, rooted in provisions from the Inflation Reduction Act (IRA) of 2022, codifies cost-sharing improvements, enhances beneficiary protections, and imposes new requirements on plan sponsors and pharmacies.
While the rule encompasses various critical policy updates, marketing and communication practices receive a partial overhaul. Let’s dive into the changes with a deeper look at the updated marketing standards.
Key Provisions of the 2026 Final Rule
- Vaccine Cost-Sharing Reforms: CMS codifies that all adult vaccines recommended by the Advisory Committee on Immunization Practices (ACIP) must be offered under Part D with zero cost-sharing. This rule applies to both in-network and out-of-network settings, effective from January 1, 2023, and continuing forward.
- Codification of SSBCI Oversight: CMS has codified guidelines for Special Supplemental Benefits for the Chronically Ill (SSBCI), reinforcing that benefits must be medically appropriate and aimed at improving or maintaining health. Non-allowable items—such as tobacco, alcohol, and firearms—are now explicitly excluded, ensuring that SSBCI focuses on meaningful, health-related interventions. Plans must adhere to stricter documentation and compliance standards.
- Insulin Cost-Sharing Cap: Beginning in 2026, insulin costs under Part D will be limited to the lesser of $35/month, 25% of the drug’s Maximum Fair Price, or 25% of the negotiated price.
- Medicare Prescription Payment Plan: This provision allows all Part D enrollees, including those receiving subsidies, to pay their out-of-pocket costs in capped monthly payments rather than upfront at the point of sale.
- Enhanced Protections for Dually Eligible Beneficiaries (D-SNPs): New federal requirements mandate that applicable integrated D-SNPs issue integrated ID cards that cover both Medicare and Medicaid benefits and conduct a combined Health Risk Assessment (HRA) for both programs.
- Prescription Drug Event (PDE) Timeliness Requirements: Initial PDEs must be submitted within 30 days, adjustments and deletions within 90 days, and selected drugs have a 7-day window.
- Pharmacy Requirements in the Drug Price Negotiation Program: Pharmacies must enroll in the Medicare Transaction Facilitator Data Module (MTF DM) to ensure accurate pricing and claims for drugs with negotiated prices.
Spotlight: Marketing and Communication Reforms
One of the most impactful sections of this final rule is CMS’s ongoing effort to strengthen marketing oversight and ensure beneficiaries receive accurate, accessible, and meaningful information.
Integrated Member ID Cards: For CY 2027, all integrated D-SNPs must issue a single, integrated ID card that serves as the enrollee’s Medicare and Medicaid card. This aims to reduce confusion, enhance the member experience, and support seamless care navigation. Plans must incorporate these changes into marketing and communication materials starting October 1, 2026.
Medicare Prescription Payment Plan Communications: Marketing and outreach materials must now include eligibility criteria and enrollment details, monthly payment cap explanations, instructions for opting in or out, and changes in timing for renewal and election notices. Telephonic notices must meet revised content requirements, long-term care pharmacies are tasked with delivering a “Likely to Benefit” notice, and pharmacies are no longer required to provide OOP estimates at the point of sale.
Transparency and Clarity in Plan Information: Though not finalized in this rule, CMS reiterated its watchful eye on third-party marketing organizations (TPMOs). It continues to monitor misleading advertising, inadequate disclaimers, and aggressive marketing practices targeting seniors. CMS also emphasizes its commitment to promoting culturally and linguistically appropriate services, ensuring websites include up-to-date and accessible plan information, and educating pharmacists and physicians on reimbursement and direct member reimbursement (DMR) protocols.
Financial Impact Summary
- Vaccines: No expected financial impact.
- Insulin: Estimated $1.2B increase in transfers from 2026-2035.
- Payment Plan: No significant financial impact expected.
- D-SNP Integration: Minor administrative costs only.
Conclusion
CMS’s 2026 final rule represents a significant step forward in improving affordability, access, and accountability across Medicare Advantage and Part D programs. For insurance professionals, these updates, especially the enhanced marketing and communication requirements, underscore the critical responsibility you hold in ensuring beneficiaries receive clear, accurate, and timely information.
As trusted advisors, your expertise will be pivotal in helping individuals navigate the evolving landscape, understand their options, and choose plans that best align with their unique health and financial needs. The introduction of features like the Medicare Prescription Payment Plan and integrated member ID cards present new opportunities to streamline the enrollee experience but also demand precise communication and personalized support.
Stay engaged as further guidance is released, particularly around implementation timelines and materials, so you can continue to deliver exceptional service and uphold your role as a key resource in the Medicare journey.
1 (800) 772-6881 x7731 | sales@pfsinsurance.com
Bob Brzyski
Vice President Marketing
Contact a Pinnacle Representative if you have any questions.
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