Medicare Seeks Tighter Coverage Denial Rules for Private Plans (1)

Medicare managed care plans would face tighter restrictions and increased scrutiny of their prior authorization activity in 2026 under a proposed rule released Tuesday by the Biden administration.

In addition to proposing Medicare and Medicaid cover anti-obesity drugs for weight loss, the Contract Year 2026 Medicare Advantage and Part D proposed rule (RIN 0938-AV40) would clarify when private MA plans can apply prior authorization and other utilization management techniques by defining the meaning of “internal coverage criteria,” the Centers for Medicare & Medicaid Services announced.

The proposal would also require plans to inform enrollees of their rights to ...