Good denial news: 2026 Medicare Advantage Final Rule prevents MA plans from reopening previously approved inpatient admissions

By Brian Murphy

CMS in April released the 2026 Medicare Advantage final rule. Here’s three important items you should know about.

Between this and the 2026 IPPS proposed rule we’re drowning in rules, so if you hope to stay on top it’s important to read what experts have to say. One such person is Richelle Marting, Healthcare Reimbursement Attorney for Marting Law, LLC, whom I’ve gotten to know through hosting her on the Off the Record podcast. I recommend following her on LinkedIn, as her coverage of the MA final rule has been fantastic.

• No coverage for anti-obesity medications. I’m of a mixed mind about this; obesity is obviously a major problem nationwide and reigning it in will help improve quality of life for countless millions. Ozempic, Wegovy, etc. work. However these drugs are expensive, non-obese will have to help cover the costs in the form of rising premiums, and there is still a place for agency/personal responsibility when it comes to health.

• Punting on artificial intelligence. This is again, like anti-obesity medications, an incredibly complicated issue. AI is everywhere; in my professional niche (healthcare marketing) the advent of AI has been like the dawn of fire; it’s revolutionary, all anyone talks about. With AI you can outsource your writing or visual art; you can even outsource your thinking. AI can help doctors not just write a progress note but render a diagnosis. Unfortunately we don’t really understand how AI works, their algorithms are impossible for a layman to decipher, and they can hallucinate results. But there is fear that if we stop to regulate the tech we’ll fall behind other adversarial nation-states. So, CMS is punting.

• No retroactive inpatient stay denials. CMS finalized a provision that restricts MA plans’ ability to reopen and modify a previously approved inpatient hospital decision on the basis of information gathered after the approval. Under this final rule, MA plans will only be able to reopen an approved admission for obvious error or fraud. Marting has done some great work here pulling out numerous relevant quotes regarding MA coverage obligations from the rule. Here’s a few: 

• “We are finalizing our proposal to restrict plans’ ability to use information gathered after the inpatient admission has taken place when reviewing the appropriateness of the admission itself.” Why this is important: the decision on admission status is made based on what is known at the time the decision to admit is made, not with 20/20 hindsight on what transpired throughout the stay.
• “For 2024, CMS clarified via regulation its longstanding policy that prior authorizations by MA plans are advance approval of coverage and payment that cannot be reopened without good cause. It gets better in 2026. “In the same way that a provider and enrollee reasonably rely upon an MA organization’s approval of a prior authorization before services are rendered, an approval of inpatient or outpatient services during a concurrent review is an organization determination that is relied upon by the enrollee and provider to continue delivering medically necessary services that they expect to be covered and paid for by the MA organization.”

References

• Becker’s, https://www.beckersasc.com/asc-coding-billing-and-collections/cms-posts-medicare-advantage-final-rule-5-things-to-know/ 
• CMS, Contract Year 2026 Policy and Technical Changes to the Medicare Advantage Program: https://www.cms.gov/newsroom/fact-sheets/contract-year-2026-policy-and-technical-changes-medicare-advantage-program-medicare-prescription-final