With Some Changes, Proposed Regulations on Medicare Advantage and Part D Prescription Drug Coverage Would Improve Care for Medicare Enrollees

WASHINGTON DC — In a comment letter filed today, America’s Physician Groups (APG) said that changes proposed by the Centers for Medicare & Medicaid Services (CMS) to the Medicare Advantage (MA) program and Medicare Part D would improve care and outcomes for Medicare beneficiaries. But APG also said that refining some of these changes even further would be optimal, in large part because they would improve the ability of health care providers to address their patients’ care needs.

“CMS’s proposed changes reflect the ongoing evolution of the Medicare Advantage program and will go a long way toward improving the health care that beneficiaries receive,” said APG President and CEO Susan Dentzer. “With some additional minor changes, the improvements for patients would be even greater.”

As proposed by CMS, important changes in MA and Part D would include the establishment of guardrails for agents and brokers to protect against anti-competitive behavior in the marketing of MA plans; enhanced transparency related to prior authorization requests; expansion of access to mental health services; and more flexibility for Part D plans to provide lower-cost biosimilar prescription drugs. In its letter, APG recommended that most of these proposed changes be finalized as proposed.

At the same time, APG also recommended that CMS make refinements to some of its proposed changes to protect against unintended consequences of new regulatory requirements. APG singled out three key areas, as follows:

  • An important topic that APG addressed was the use of supplemental benefits in MA, and in particular, a class of these benefits known as Special Supplemental Benefits for the Chronically Ill. Even as the offering of supplemental benefits by MA plans has proliferated, little is known about the effectiveness — and cost-effectiveness — of these benefits in improving outcomes for enrollees, including the impact on disadvantaged populations.

As a result, APG recommended that CMS set a short-term goal of collecting detailed information from MA organizations (MAOs) about evidence of the impact of supplemental benefit utilization on enrollees’ quality of care outcomes and out-of-pocket costs, and that CMS analyze and report its findings. Other proposed steps involving these benefits should be deferred until the results of such studies are published.

  • APG also welcomed CMS’s ongoing commitment to addressing health equity, and shares agency’s concern that prior authorization and other utilization management tools may present a challenge to achieving this goal. Thus, APG supported CMS’s proposals about studying the extent to which MAOs may need to revise their use of these utilization management tools. But it also recommended that CMS convenea technical expert panel in the second half of 2026, following the release of the MAO utilization studies, to assess the findings and consider options for addressing any problems discovered.

  • APG also addressed the important topic of Risk Adjustment Data Validation (RADV) audits that CMS is now conducting to address improper overpayments to MAOs. During such audits, CMS confirms that any diagnoses submitted by an MAO for risk adjustment are supported in the enrollee’s medical record. CMS and the Department of Justice can not only recoup three times the amount of any overpayment due to erroneous or inflated risk adjustment, but can also impose separate monetary payments under the False Claims Act. But it is not specified in law or regulation how MAOs should come up with these payment recoupments and penalties, and as a result, they may attempt to claw back payments to health care providers that did not participate in any of the risk adjustment activities in question.

APG thus recommended that CMS propose requirements that would ensure that Risk Adjustment Data Validation (RADV) monetary penalties be applied to providers or other actors that contributed to a negative RADV finding as part of the 2026 MA rulemaking process, rather than indiscriminately to providers that are not responsible for these negative findings.

With all of these changes, the body of regulatory amendments that CMS proposes would unequivocally accomplish CMS’s goals of improving care and outcomes for Medicare Advantage and Part D enrollees. APG looks forward to working with the agency to accomplish these critically important changes in the programs.

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About America’s Physician Groups
APG is the largest U.S. organization of physicians committed to being held accountable for costs and quality of health care, and who collectively care for roughly one-third of MA enrollees nationwide. More than half of Medicare beneficiaries are now enrolled in MA plans (Part C).

APG’s approximately 360 physician groups comprise 170,000 physicians, as well as thousands of other clinicians, providing care to nearly 90 million patients. APG’s motto, ‘Taking Responsibility for America’s Health,’ represents our members’ commitment to clinically integrated, coordinated, value-based health care in which physician groups are accountable for the costs and quality of patient care. Visit us at www.apg.org.


Contact: Greg Phillips, APG Director of Communications, 202-770-1901