On December 10, 2024, the Centers for Medicare & Medicaid Services (CMS) published a proposed rule with technical changes for the Medicare Advantage (MA) Program and the Medicare Prescription Drug Benefit Program for Calendar Year 2026 (Proposed Rule). Citing the growing use of Artificial Intelligence (AI) within the healthcare sector and reports that the use of AI may lead to “algorithmic discrimination” that exacerbates inequalities within healthcare, CMS proposes, for the first time, new guardrails that must be adopted by MA plans when using AI to manage patient care. CMS also proposes several reforms addressing utilization management (UM) techniques adopted by MA plans, including requirements for such plans to conduct and report detailed analyses on the use of prior authorizations. Notably, the Proposed Rule primarily modifies MA regulations, without direct application to the Medicare Part D prescription drug program.

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