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What the 2025 CMS Updates Mean for Providers (and Their Implications for 2026) Pt. 2

In Part 1, we examined the major developments around the RADV audit rule and what the court’s decision means for Medicare Advantage plans and providers. But the 2025 CMS landscape reaches well beyond RADV. A wide range of new Medicare Advantage (Part C) and Part D updates are also taking effect; each designed to tighten oversight, strengthen patient protections, and streamline administrative processes. For providers, these changes bring both new opportunities and new expectations. Below is a summary of more impactful updates you should be aware of as we head into 2026.

Medicare Advantage & Part D Policy Changes for 2025

Beyond the RADV audits, CMS has implemented a host of Medicare Advantage (Part C) and Part D updates for Contract Year 2025 that providers should know – many aimed at protecting patients and improving care quality. Key changes include:

  • Behavioral Health Access: MA plans must enhance access to behavioral health services. CMS now requires plans to add more mental health and substance use disorder providers in their networks and to remove unnecessary barriers to behavioral health care[30]. For providers, this could mean increased contracting opportunities for mental health professionals and easier referrals for patients who need therapy or psychiatry.
  • Marketing and Broker Oversight: CMS is cracking down on misleading marketing and sales tactics. Broker commissions are now capped and standardized, and volume-based enrollment bonuses are prohibited (especially for Dual-Eligible SNP plans)[30]. Third-party marketing organizations face new limits on how they can use beneficiary data[30]. This should translate to less confusion for patients and more reliable information when they choose plans. Providers might see fewer patients switching plans due to questionable marketing, reducing disruption in care continuity.
  • Utilization Management & Appeals: CMS will require plans to annually review their utilization management (UM) policies with an eye on health equity[30]. In practice, this means MA plans must examine if processes like prior auth or coverage denials are impacting certain patient groups unfairly and make adjustments. Also, the appeals process is being streamlined for certain scenarios – for example, if an MA plan terminates coverage of a post-acute care service (like ending skilled nursing facility days early), enrollees will have a more straightforward path to appeal that decision[31]. For providers advocating on behalf of patients, a more uniform and user-friendly appeals system should ease the burden of fighting inappropriate denials.
  • Protections for Dual-Eligibles: For MA Special Needs Plans serving patients on both Medicare and Medicaid, out-of-network cost sharing is now limited[31]. This prevents low-income patients from being saddled with huge bills if they unknowingly see an out-of-network provider. As a provider, if you treat dually-eligible patients, you may encounter fewer unpaid charges, since patients won’t be penalized as heavily for out-of-network care in certain plan types.
  • Part D Prescription Changes: The Part D program also saw updates. Plans have more flexibility to substitute generics or biosimilars for brand-name drugs mid-year to reflect new product availability[31]. There’s also the ongoing implementation of the Inflation Reduction Act changes (like the $2,000 out-of-pocket cap in Part D by 2025) which will affect medication adherence and possibly increase demand for services as drug affordability improves. Providers, especially those in primary care and pharmacy, should be prepared for formulary adjustments and help patients navigate stable therapy options if a switch to a biosimilar occurs.
  • Provider Directories: Looking ahead to 2026, a new rule will require MA plans to submit their provider directory data to CMS for the Medicare Plan Finder and keep it updated within 30 days of any changes[32]. Plans must attest yearly to the accuracy of their directories. This is intended to reduce the frustrating phenomenon of outdated directories. For healthcare providers, this means you should ensure any changes in your practice (address, accepting new patients, etc.) are promptly communicated to the MA plans you participate in. An accurate directory will help patients find you and avoid misdirected appointments.

Overall, these policy tweaks signal that CMS is holding Medicare Advantage plans to higher standards in 2025. Providers can expect fewer administrative headaches caused by plan missteps – for instance, hopefully less time spent correcting directory errors or wrestling with opaque denials. However, providers may also face greater expectations from plans to document medical necessity thoroughly and to coordinate care, as CMS pushes plans to justify their practices. It’s a good idea to familiarize yourself with the specific MA plans common in your patient population and understand how they’re implementing these new CMS rules.

No Surprises Act: Extended Uncertainty in Out-of-Network Billing

In parallel to CMS’s actions, 2025 saw continued developments in the No Surprises Act (NSA) – the law protecting patients from surprise out-of-network bills. The NSA’s independent dispute resolution (IDR) process has been tumultuous, and recent legal challenges have affected how payment amounts are determined.

Most notably, federal regulators extended their “enforcement discretion” on the NSA’s Qualified Payment Amount (QPA) calculation through early 2026[33]. The QPA (generally the median in-network rate) is a critical factor in deciding how much insurers pay out-of-network providers in arbitration. Courts found flaws in the QPA formula set in the original 2021 rule, and litigation (the Texas Medical Association cases) is ongoing[34][35]. In response, agencies have allowed insurers to keep using the 2021-era QPA methods until at least Feb 1, 2026 (and possibly through Aug 2026)[33][36].

  • Impact: For providers, this means the IDR process remains in a holding pattern. The payment offers you receive in arbitration will likely continue to be anchored to insurers’ QPA calculations that physicians argue are artificially low[37]. While the pause provides short-term stability (avoiding constantly changing rules), it also prolongs the under-payment concerns physician groups have raised (i.e. that current QPAs give insurers an upper hand, driving down reimbursements)[38]. If you practice in a specialty or region where out-of-network billing is common (e.g. emergency medicine, pathology, radiology, or elective specialties with narrow networks), be aware that NSA disputes in 2025-2026 will use essentially the status quo rules. It’s advisable to continue negotiating in good faith with payers when possible and document thoroughly to support your claims in IDR. The long-term resolution – a final formula for fair out-of-network rates – is still pending further court decisions and potential regulatory revisions. Keep an eye on updates around mid-2026, as the landscape could shift if the Fifth Circuit or Congress takes action.

Preparing for 2026: Key Takeaways for Providers

The policy changes of 2025 underscore a few themes that providers should carry into 2026:

  • Enhanced Oversight vs. Administrative Relief: CMS is simultaneously cracking down on problematic practices (MA overpayments, marketing abuses, etc.) and trying to streamline burdensome processes (prior auth, appeals). For providers, this means tighter alignment with documentation and compliance standards, but fewer hoops to jump through in doing so. You may need to invest time in ensuring accurate coding (to withstand audits) even as some paperwork gets easier.
  • Financial Planning: With Medicare fees getting a small bump, adjust your 2026 budget and payer contracting expectations accordingly. But remain cautious – the conversion factor patch is temporary[17]. Also, if you see a large Medicare Advantage population, be aware that MA plan revenue will likely stay stable in 2026 (premiums are actually projected to slightly decrease on average), so major changes in MA reimbursement to providers aren’t expected in the near term. However, if CMS succeeds with future RADV audits or other payment clawbacks, plans might tighten provider rates down the line.
  • Stay Informed and Engaged: Many 2025 updates require active participation from providers to realize their benefits. For example, take advantage of any new electronic prior auth tools your payers offer – these could significantly cut lag time for approvals once implemented. Similarly, if telehealth rules change in late 2025, be ready to pivot: e.g., consider advocating for patients who might lose access, and explore offering services (like mental health) that will retain telehealth eligibility. Engage with professional societies (AMA, specialty associations) who are tracking these issues – they often provide guidance or templates (like how to prepare for the end of telehealth waivers or how to handle NSA disputes under current rules).

In conclusion, 2025’s CMS updates bring a mix of opportunities and challenges for providers. We’re seeing a healthcare system in flux – one that is addressing long-standing issues like overpayments and care access gaps, albeit with some legal wrangling along the way. As we head into 2026, providers who understand these changes and adapt proactively will be best positioned to continue delivering high-quality care while maintaining financial and regulatory health for their practices. The bottom line: stay agile, keep documentation pristine, and leverage the new tools and flexibilities designed to support patient care. The policy winds may shift, but the focus on value and accountability is here to stay,[12]  and providers are at the heart of making those goals a reality.

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