in effect
This is a final rule issued by the Centers for Medicare & Medicaid Services (CMS) that updates the regulations governing Medicare Advantage (Part C), the Medicare Prescription Drug Benefit (Part D), Medicare Cost Plans, and Programs of All-Inclusive Care for the Elderly (PACE) for contract year 2026. It primarily writes into binding federal regulation several policies that were previously enacted by the 2022 Inflation Reduction Act or communicated through informal agency guidance.
Adult vaccines recommended by the CDC’s Advisory Committee on Immunization Practices (ACIP) and covered under Part D are now subject to $0 deductible and $0 cost sharing, effective for plan years beginning January 1, 2023 and forward. Insulin cost sharing is capped at no more than $35 per month’s supply for 2023–2025, with the 2026 cap set at the lowest of $35, 25% of the federally negotiated maximum fair price, or 25% of the plan’s negotiated price. Medicare Part D enrollees now have the right to spread their out-of-pocket prescription drug costs into monthly installments across the plan year through the Medicare Prescription Payment Plan, rather than paying the full amount at the pharmacy. Drug plans must submit initial prescription drug event records to CMS within 30 calendar days of receiving a claim (7 days for drugs subject to federal price negotiation). Dual-eligible enrollees in integrated Medicare-Medicaid plans will receive a single combined member ID card and a single combined health risk assessment instead of separate ones for each program.
Medicare Part D enrollees — including those in standalone drug plans and Medicare Advantage plans with drug coverage — benefit from the cost-sharing caps on vaccines and insulin and gain the installment-payment option. Insurance organizations that operate Medicare Advantage or Part D plans, and the pharmacies in their networks, face new administrative requirements including tighter data submission deadlines, mandatory enrollment in the Medicare Transaction Facilitator Data Module, and updated notice and outreach obligations.