Key CMS 2026 Medicare Advantage Final Rule Updates for Insurers

CMS has released the final rule for the 2026 Medicare Advantage program, outlining several key policy updates impacting healthcare payers and providers. First, the rule excludes coverage for anti-obesity medications such as Ozempic and Wegovy. While these drugs have demonstrated effectiveness, their high costs may increase premiums for non-obese enrollees, highlighting concerns over financial impacts and the balance of personal responsibility in health management. Second, CMS has deferred regulatory action on the use of artificial intelligence (AI) technologies in Medicare Advantage. Despite AI's growing role in clinical documentation and diagnostic support, CMS is withholding regulation amid uncertainties about algorithm transparency and potential inaccuracies, aiming to avoid falling behind global technological advancements. Lastly, the rule limits Medicare Advantage plans' ability to retroactively deny inpatient hospital stays. Plans can no longer reopen admissions decisions based on new information unless clear errors or fraud are identified, stabilizing approvals made during concurrent review and reinforcing reliance on initial clinical judgments. This change builds on prior guidance emphasizing the binding nature of prior authorizations once granted. These updates reflect CMS's approach to balancing innovation, cost management, and provider-enrollee trust within the Medicare Advantage framework. The provisions will influence plan design, risk management practices, and compliance strategies across the payer and provider landscape.