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LATEST INDUSTRY UPDATES
May, 2025
Key Provisions: 2026 Medicare Advantage & Part D Final Rule
The 2026 Contract Year Final Rule for Medicare Advantage (MA) and Part D Prescription Drug Plans largely fell flat in comparison to previous rulemaking cycles. However, CMS has prioritized the codification of Inflation Reduction Act (IRA) provisions, operational updates, and further steps toward integration for dual-eligible populations. While it was less flashy than expected, these changes will influence plan administration, benefit design, and member experience.
Unlike some recent cycles, the 2026 final rule does not introduce broad new coverage requirements. Many proposals from prior cycles—such as expanded anti-obesity drug coverage or additional changes to network and marketing rules—were not finalized. The emphasis this year is on finalizing IRA mandates, updating beneficiary protections, and operational integration, particularly for special needs plans. For MA organizations and Part D sponsors, the focus is on compliance with updated benefit requirements and preparation for the related operational changes.
Mid-Year Strategy: Aligning Star Ratings and Overall Performance
As we enter the second half of 2025, health plans and provider organizations are approaching a critical strategic inflection point. With the final push to close out 2026 health plan products, HEDIS® seasons and CAHPS® surveys—and the ongoing need for momentum in gap closure and revenue optimization through prospective and retrospective reviews— the stakes are high.
In value-based programs like Star Ratings, risk adjustment, quality, and total cost of care, there are three parallel tracks:
- Rear-view analytics and data collection, including evaluating the impact of prior-year initiatives and looking forward to Star Ratings, risk revenue and final incentives payouts to providers
- Real-time execution by delivering on current priorities for members and patients that affect next year’s business results and health outcomes
- Forward investment through building infrastructure, modernizing technology, and exploring new benefits and programs to shape outcomes for the next two years
It’s a tall order, especially in the face of shifting federal, CMS and state regulations, combined with a rapidly evolving technology landscape.
Read on for five steps to build sustainable Star results and a high-performing organization.
CMS RADV Audit Expansion Alert: Major Changes for Medicare Advantage Plans
CMS is rolling out the most sweeping RADV audit expansion in Medicare Advantage history—and it will impact every single MA contract moving forward. Here's what's changing:
- Industry-Wide Audits: CMS plans to conduct a RADV audit on all eligible contracts each payment year (previously ~60 annually)
- More Records Per Audit. The number of records reviewed per plan will jump from an average of 35 to as many as 200, depending on plan size
- Massive Coder Expansion. CMS is increasing its coding team from 40 to 2,000 by September 1 to manually verify flagged diagnoses
- Enhanced Tech-Driven Audit. Advanced tools will be deployed to detect diagnoses unsupported in medical records
- HHS-OIG Partnership. CMS will work with the Office of Inspector General to recover historical overpayments uncovered in past audits
ATTAC Consulting Provides MA-RADV Support
- Expert Coding Resources to Validate Diagnoses in Charts. Our RADV audit and coding team can support your RADV response by reviewing medical records to validate diagnoses; we’ll also help identify “best charts” for submission
- Leading-Edge, Tech-Enabled Coding Platform. Our tech -riven coding platform helps our coders rapidly identify support for targeted diagnoses and identification of new unreported diagnoses
- Update Compliance Programs & Test High-Risk Areas. ATTAC can help align internal policies with CMS’s updated audit protocols and conduct proactive audits to address high-risk areas
Plan Ahead! Line Up Capacity for RADV Support Now
The competition for resources, including chart retrieval and coding, may be intense during Medicare Advantage RADV season. Contact us to talk with a RADV expert now and learn more about ATTAC's RADV audit support here.
ATTAC On The Road
Medicare Stars, HEDIS®, Quality & Risk Summit June 3-5 | Chicago
Subbu Ramalingam, ATTAC Managing Director, will join the panel, Strategies to Improve Performance Scores in the Face of Fierce Competition, Regulatory Uncertainty, Financial Challenges, and Changing Demographics
Federal Communications Pause: CMS Hasn’t Updated Appeals Decisions Since Jan. 20
Secret Shopper Surveys: QHPs Face May 31 Deadline to Meet CMS’s New Access-to-Care Requirements
Regulatory Freeze: How Medicare Advantage Plans Can Balance Challenges with Opportunities for Growth
A New Administration, a New Healthcare Landscape: What Health Plans and Providers Need to Know