The Centers for Medicare & Medicaid Services (CMS) released a proposed rule with new policies for the Medicare Advantage (MA) and Part D programs for contract year 2026.
With a change in administrations looming, it is not assured that any of the policies in this proposal will ever be finalized. Comments on the proposed rule are due January 27, 2025, after the January 20 inauguration of President-elect Donald Trump. This means it will be left to the Trump Administration to finalize—or ignore—what the agency has just proposed.
The most prominent proposal is a reinterpretation of a provision of the Social Security Act that excludes "[a]gents when used for anorexia, weight loss, or weight gain" from Part D coverage and permits Medicaid programs to exclude those drugs from coverage. Historically, CMS has interpreted this clause to exclude coverage for anti-obesity medications (AOMs), such as GLP-1s, except as supplemental benefits or when prescribed for conditions other than obesity. Now, recognizing obesity as a distinct disease, CMS proposes to reinterpret the text to permit coverage of AOMs in Part D when used for weight loss or chronic weight management for the treatment of obesity (though not for weight loss or chronic weight management in individuals who are overweight and lack other diagnoses). CMS would also apply this reinterpretation to Medicaid, which would make AOM coverage for treatment of obesity mandatory, rather than optional, in state Medicaid programs.
The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.
