Medicare Advantage · Part C
Medicare Advantage regulatory monitoring
CMS changes the rules that govern the Medicare Advantage (Part C) program every year — Contract Year policy and technical changes, payment policies, and program notices. We track them as they publish in the Federal Register and OIG, and link the source document on every one, so your revenue-cycle and compliance teams can act before the change reaches your claims.
Prior-authorization divergence — MA vs. Traditional Medicare
CY2026 · 7,420 plan-segmentsTraditional Medicare applies prior authorization narrowly — a published list of specific items, enumerated by HCPCS code, plus select hospital outpatient services. Medicare Advantage plans apply it at the benefit-category level. That difference in scope is the divergence, and it is why an MA claim denies where the same service under Traditional Medicare would not have needed authorization at all.
Every figure below is counted directly from the CMS Plan Benefit Package (PBP) public extract ↗ for CY2026 — 7,420 MA plan-segments. Nothing is modeled or estimated.
| Medicare Part A/B benefit category | Plans requiring prior auth | Yes | No |
|---|---|---|---|
| Durable medical equipment (DME)§11a | 98.3% | 6,857 | 119 |
| Medical supplies§11b | 97.9% | 6,830 | 146 |
| Inpatient hospital — acute§1a | 97.6% | 6,686 | 165 |
| Part B prescription drugs§15 | 97.1% | 6,757 | 204 |
| Skilled nursing facility (SNF)§2 | 96.5% | 6,611 | 240 |
| Outpatient diagnostic radiology§8b | 95.5% | 6,665 | 311 |
| Ambulatory surgical center (ASC)§9b | 95.4% | 6,656 | 320 |
| Outpatient clinical / diagnostic / therapeutic§8a | 95.2% | 6,641 | 335 |
| Inpatient hospital — psychiatric§1b | 94.7% | 6,485 | 366 |
| Ambulance§10a | 93.9% | 6,547 | 429 |
| Home health§6 | 92.7% | 6,493 | 509 |
| Partial hospitalization§5a | 89.7% | 6,282 | 720 |
| Diabetes monitoring supplies§11c | 85.6% | 5,969 | 1,007 |
| Intensive outpatient services§5b | 83.0% | 5,814 | 1,188 |
| Opioid treatment services§7k | 80.8% | 5,636 | 1,340 |
| Physical therapy / speech therapy§7i | 79.4% | 5,539 | 1,437 |
| Outpatient substance-abuse services§9c | 79.0% | 5,512 | 1,464 |
| Occupational therapy§7c | 78.6% | 5,486 | 1,490 |
| Mental health specialty services§7e | 78.1% | 5,451 | 1,525 |
| Psychiatric services§7h | 77.6% | 5,414 | 1,562 |
| Chiropractic services§7b | 70.7% | 4,930 | 2,046 |
| Other health care professional§7g | 68.9% | 4,807 | 2,169 |
| Cardiac rehabilitation§3 | 68.2% | 4,758 | 2,218 |
| Physician specialist visits§7d | 65.3% | 4,557 | 2,419 |
| Renal dialysis§12 | 63.1% | 4,404 | 2,572 |
| Podiatry services§7f | 59.3% | 4,135 | 2,841 |
| Hearing exams (Medicare-covered)§18a | 52.1% | 3,633 | 3,343 |
| Outpatient blood services§9d | 48.3% | 3,368 | 3,608 |
| Eye exams (Medicare-covered)§17a | 47.4% | 3,308 | 3,668 |
| Telehealth§7j | 24.9% | 1,362 | 4,117 |
| Preventive services ($0 cost-share)§14a | 11.8% | 822 | 6,154 |
| Kidney disease education§14d | 9.5% | 661 | 6,315 |
Percentages are computed over plans that answeredthe PBP authorization question; plans that left it blank are excluded from the denominator, never counted as “No” — so the rate is not inflated or deflated by non-responses. Only Medicare Part A/B categories are shown: CMS marks supplemental benefits (dental, OTC, meals, hearing aids) “non-Medicare-covered,” and Traditional Medicare does not cover them at all, so prior authorization there is not a divergence.
Tracked MA regulatory changes
29 tracked- final ruleEffective 2026-06-01· Medicare Advantage
Federal Register Final Rule: Medicare Program; Contract Year 2027 and Certain Contract Year 2026 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, and Medicare Cost Plan Program
New Medicare Advantage policies impact billing and reimbursement.
- federal ruleEffective 2026-04-14· Medicare Advantage
Medicare and Medicaid Programs; Patient Protection and Affordable Care Act; Interoperability Standards and Prior Authorization for Drugs for Medicare Advantage Organizations, Medicaid Managed Care Plans, State Medicaid Agencies, Children's Health Insurance Program (CHIP) Agencies and CHIP Managed Care Entities, and Issuers of Qualified Health Plans on the Federally-Facilitated Exchanges
Final Rule published 2026-04-14. These proposals are intended to improve the electronic exchange of health care data and streamline processes related to prior authorization by increasing the interoperability of systems used across the health care industry. We are proposing new requirements for Medicare Advantage (MA) organizations, state Medicaid fee-for-service (FFS) programs, state Children's Health Insurance Program (CHIP) FFS
- federal ruleEffective 2026-04-06· Medicare Advantage
Medicare Program; Contract Year 2027 and Certain Contract Year 2026 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, and Medicare Cost Plan Program
Final Rule published 2026-04-06. This final rule revises the Medicare Advantage (Part C), Medicare Prescription Drug Benefit (Part D), and Medicare cost plan regulations to implement changes related to Star Ratings, marketing and communications, drug coverage, enrollment processes, special needs plans, and other programmatic areas.
- federal ruleEffective 2026-02-25· Medicare Advantage
Managed Care
Final Rule published 2026-02-25.
- final ruleEffective 2025-11-17· Medicare Advantage
Federal Register Final Rule: Medicare and Medicaid Programs; Contract Year 2026 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicare Cost Plan Program, and Programs of All-Inclusive Care for the Elderly (PACE)-Finalization of Format Provider Directories for Medicare Plan Finder
Changes to Medicare Advantage directory requirements finalized.
- final ruleEffective 2025-06-03· Medicare Advantage
Federal Register Final Rule: Medicare and Medicaid Programs; Contract Year 2026 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicare Cost Plan Program, and Programs of All-Inclusive Care for the Elderly
Important updates for Medicare Advantage and drug benefits.
- final ruleEffective 2024-06-03· Medicare Advantage
Federal Register Final Rule: Medicare Program; Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit Program for Contract Year 2024-Remaining Provisions and Contract Year 2025 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicare Cost Plan Program, and Programs of All-Inclusive Care for the Elderly (PACE)
Medicare Advantage changes impact funding and care coordination.
- final ruleEffective 2024-04-08· Medicare Advantage
Federal Register Final Rule: Medicare and Medicaid Programs; Patient Protection and Affordable Care Act; Advancing Interoperability and Improving Prior Authorization Processes for Medicare Advantage Organizations, Medicaid Managed Care Plans, State Medicaid Agencies, Children's Health Insurance Program (CHIP) Agencies and CHIP Managed Care Entities, Issuers of Qualified Health Plans on the Federally-Facilitated Exchanges, Merit-Based Incentive Payment System (MIPS) Eligible Clinicians, and Eligi
New rule to enhance data exchange & streamline prior authorization.
- final ruleEffective 2024-02-12· Physician Fee Schedule
Federal Register Final Rule: Medicare and Medicaid Programs; CY 2024 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies; Medicare Shared Savings Program Requirements; Medicare Advantage; Medicare and Medicaid Provider and Supplier Enrollment Policies; and Basic Health Program; Corrections
Updates correct errors in Medicare payment rules, impacting billing.
- final ruleEffective 2024-01-01· Physician Fee Schedule
Federal Register Final Rule: Medicare and Medicaid Programs; CY 2024 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies; Medicare Shared Savings Program Requirements; Medicare Advantage; Medicare and Medicaid Provider and Supplier Enrollment Policies; and Basic Health Program
Major updates to Medicare reimbursement policies effective Jan 2024.
- final ruleEffective 2023-12-11· Multi-specialty
Federal Register Final Rule: Medicare Program; Medicare Secondary Payer and Certain Civil Money Penalties
New fines for Medicare Secondary Payer reporting failures.
- final ruleEffective 2023-08-08· Hospital Outpatient (OPPS)
Federal Register Final Rule: Medicare Program; Treatment of Medicare Part C Days in the Calculation of a Hospital's Medicare Disproportionate Patient Percentage
Changes in Medicare Advantage days affect hospital reimbursements.
- final ruleEffective 2023-06-05· Medicare Advantage
Federal Register Final Rule: Medicare Program; Contract Year 2024 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicare Cost Plan Program, and Programs of All-Inclusive Care for the Elderly
New rules affect billing processes in Medicare Advantage programs.
- final ruleEffective 2023-04-03· Medicare Advantage
Federal Register Final Rule: Medicare and Medicaid Programs; Policy and Technical Changes to the Medicare Advantage, Medicare Prescription Drug Benefit, Program of All-Inclusive Care for the Elderly (PACE), Medicaid Fee-For-Service, and Medicaid Managed Care Programs for Years 2020 and 2021
New Medicare Advantage rule set to alter payment audit processes.
- federal register· Multi-specialty
Federal Register Notice: Medicare Program; Inflation Reduction Act of 2022 (IRA) Medicare Drug Price Negotiation Program Draft Guidance; Comment Request
CMS seeks comments on IRA drug price negotiation MFP guidance for 2028.
- billing update· Medicare Advantage
Federal Register Notice: Agency Information Collection Activities: Submission for OMB Review; Comment Request
CMS seeks comments on information collection impacting billing.
- billing update· Medicare Advantage
Federal Register Notice: Agency Information Collection Activities: Submission for OMB Review; Comment Request
CMS seeks public comments on information collection activities.
- billing update· Medicare Advantage
Federal Register Notice: Medicare Program; Request for Information on Medicare Advantage Data
RFI on Medicare Advantage data could impact billing practices.
- proposed rule· Medicare Advantage
Federal Register Proposed Rule: Medicare and Medicaid Programs; Patient Protection and Affordable Care Act; Interoperability Standards and Prior Authorization for Drugs for Medicare Advantage Organizations, Medicaid Managed Care Plans, State Medicaid Agencies, Children's Health Insurance Program (CHIP) Agencies and CHIP Managed Care Entities, and Issuers of Qualified Health Plans on the Federally-Facilitated Exchanges
New proposals requires billing team review.
- proposed rule· Medicare Advantage
Federal Register Proposed Rule: Patient Protection and Affordable Care Act, HHS Notice of Benefit and Payment Parameters for 2027; and Basic Health Program
New rules could reshape reimbursement structures for health plans.
- proposed rule· Medicare Advantage
Federal Register Proposed Rule: Guarding U.S. Medicare Against Rising Drug Costs (GUARD) Model
Proposed rule targets drug cost reductions in Medicare Part D.
- proposed rule· Medicare Advantage
Federal Register Proposed Rule: Medicare Program; Contract Year 2027 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, and Medicare Cost Plan Program
Proposed changes to Medicare Advantage impact billing processes.
- federal register· Medicare Advantage
Federal Register Notice: Agency Information Collection Activities: Proposed Collection; Comment Request
CMS invites public input on information collection practices.
- proposed rule· Medicare Advantage
Federal Register Proposed Rule: Medicare and Medicaid Programs; Contract Year 2026 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicare Cost Plan Program, and Programs of All-Inclusive Care for the Elderly
Major changes to Medicare Advantage may impact billing practices.
- billing update· Medicare Advantage
Federal Register Notice: Agency Information Collection Activities: Submission for OMB Review; Comment Request
Public comment opportunity on CMS information collection impacts billing.
- proposed rule· Medicare Advantage
Federal Register Proposed Rule: Patient Protection and Affordable Care Act, HHS Notice of Benefit and Payment Parameters for 2025; Updating Section 1332 Waiver Public Notice Procedures; Medicaid; Consumer Operated and Oriented Plan (CO-OP) Program; and Basic Health Program
Key payment updates could alter reimbursement strategies.
- proposed rule· Medicare Advantage
Federal Register Proposed Rule: Medicare Program; Contract Year 2025 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicare Cost Plan Program, and Programs of All-Inclusive Care for the Elderly; Health Information Technology Standards and Implementation Specifications
Key changes proposed for Medicare Advantage billing processes.
- proposed rule· Physician Fee Schedule
Federal Register Proposed Rule: Medicare and Medicaid Programs; CY 2024 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies; Medicare Shared Savings Program Requirements; Medicare Advantage; Medicare and Medicaid Provider and Supplier Enrollment Policies; and Basic Health Program
Proposed Medicare updates may alter reimbursement landscape for providers.
- fraud alert· OIG Fraud Alert
Special Fraud Alert: Suspect Payments in Marketing Arrangements Related to Medicare Advantage and Providers
OIG warns on suspect payments in Medicare Advantage marketing.
Every item is included by a deterministic match on official CMS/OIG language and links to its source document — nothing here is inferred. Regulatory monitoring is not legal, billing, or coding advice; confirm the applicable rule and effective date against the source before acting.