Medicare Advantage Plans Get 2027 Policy and Technical Refresh
Published Date: 4/6/2026
Rule
Summary
Starting January 1, 2027, Medicare Advantage, Prescription Drug, and Cost Plan programs are getting some fresh updates! These changes improve how plans are rated, marketed, and how drugs are covered, making it easier and better for millions of Medicare users. The new rules kick in June 1, 2026, so plans can get ready to serve you smarter and smoother next year.
Analyzed Economic Effects
6 provisions identified: 6 benefits, 0 costs, 0 mixed.
Annual Part D Out‑of‑Pocket Cap Set
The rule codifies an annual out‑of‑pocket (OOP) threshold of $2,000 for CY 2025 and $2,100 for CY 2026. Going forward the OOP threshold will be increased each year by the annual percentage increase and rounded to the nearest $50.
Coverage Gap Removed; Catastrophic Cost Sharing Eliminated
The rule codifies that the Part D coverage gap and initial coverage limit were eliminated beginning in CY 2025, and that once an enrollee's incurred costs exceed the annual OOP threshold they have $0 cost sharing beginning in 2024. The Part D benefit therefore has a three‑phase structure with no coverage gap in years 2025 and later.
Insulin and Vaccine Deductible and Cap Rules
The rule codifies that the Part D deductible does not apply to ACIP‑recommended adult vaccines and covered insulin products. For CYs 2023–2025 the Part D cost‑sharing amount for a one‑month supply of covered insulin products was $35; for CY 2026 and later the applicable cost‑sharing amount is the lesser of $35, 25% of the maximum fair price (MFP), or 25% of the negotiated price.
Manufacturer Discount Program Codified
The rule codifies the Medicare Part D Manufacturer Discount Program, which began on January 1, 2025 and replaces the Coverage Gap Discount Program. Manufacturers that enter into a Manufacturer Discount Program agreement are required to provide discounts on applicable drugs in both the initial and catastrophic coverage phases.
Star Ratings Measure Set Changes
CMS is simplifying and refocusing the Star Ratings measure set and will not implement the Health Equity Index reward; instead it will continue the historical reward factor. The measure removals apply to the 2027 measurement period and the 2029 Star Ratings, with the Call Center—Foreign Language Interpreter and TTY Availability measures and the Statin Therapy for Patients with Cardiovascular Disease measure applying beginning with the 2028 Star Ratings.
SSBCI Transparency and Debit Card Rules
CMS finalizes a requirement that plan‑developed eligibility criteria for Special Supplemental Benefits for the Chronically Ill (SSBCI) must be made publicly available. CMS is also codifying and clarifying requirements for administering supplemental benefits through debit cards, with modifications and without finalizing a prohibition on marketing the dollar value of supplemental benefits.
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Key Dates
Department and Agencies
Related Federal Register Documents
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Starting soon, Medicare Advantage, Medicaid, CHIP, and health plans on federal exchanges will need to use better tech to share health info and speed up drug approval requests. This means less waiting and smoother care for patients, while plans and agencies will update their systems to meet new rules. These changes aim to save time and money by making health data work together more easily, with deadlines coming in the next couple of years.
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2025-22543 — Medicare Program; Alternative Payment Model Updates and the Increasing Organ Transplant Access (IOTA) Model
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