What do the MA program rules actually require?

Chapter summaries

Chapter 1 — Medicare Advantage Organization Compliance

Compliance Establishes MAO legal and regulatory obligations — licensing, contracting, compliance program standards, delegation requirements, and the conditions for non-renewal or termination.

TL;DR: The rulebook for getting and keeping an MA contract. Compliance programs, licensing, and what triggers CMS to end your contract.

Chapter 4 — Benefits and Beneficiary Protections

Benefits Defines what benefits MA plans must cover, prohibited cost-sharing structures, and the rules for supplemental/extra benefits. Includes 2026 OTC card caps and dental coverage standards.

TL;DR: What plans must cover and what they're allowed to add. The 2026 changes raised OTC benefit caps and expanded dental coverage requirements.

Chapter 6 — Coverage Determinations, Appeals, and Grievances

Appeals Governs prior authorization, coverage determination timelines, and the appeals chain from plan level → IRE → ALJ → DAB → Federal Court. PA denial rates now feed directly into star ratings.

TL;DR: The PA and appeals process. CMS tightened timelines — plans that deny more get lower CAHPS scores, which hits star ratings hard in 2026.

Chapter 8 — SNP Model of Care Requirements

SNP Specific requirements for Special Needs Plans — Model of Care (MOC) submission, FIDE vs HIDE vs CO D-SNP distinctions, provider network adequacy for dual-eligibles, and Medicaid coordination standards.

TL;DR: The rules for running a D-SNP. FIDE-SNPs get higher rates but must fully integrate Medicaid. Most D-SNPs are CO D-SNPs with lighter integration requirements.

Chapter 11 — Medicare Marketing Guidelines

Marketing Regulates all MA plan marketing and sales materials — pre-enrollment requirements, prohibited tactics, agent/broker compensation, website standards, and TPMO (Third-Party Marketing Organization) oversight.

TL;DR: What plans can and can't say to get members. 2026 updates restrict TV ad disclaimers and added TPMO disclosure requirements on all calls.

Chapter 12 — Medicare Advantage Star Ratings

Stars The full technical framework for Part C and Part D star ratings — measure weights, data sources, cut-point methodology, and bonus payment calculations. 2026 added KED measure at 3× weight and raised CAHPS to 4×.

TL;DR: How stars are calculated and what the bonuses mean. The 2026 recalibration hit hard — CAHPS now matters more than almost any HEDIS measure.

IRA 2022 — Inflation Reduction Act — Medicare Drug Provisions

Drug Pricing The IRA authorized CMS to negotiate drug prices, capped insulin at $35/mo, phased out the coverage gap, and established the $2,100 annual Part D OOP threshold effective CY2026 (CMS Final Rule). Round 2 negotiations (2027) target 15 additional drugs.

TL;DR: The biggest change to Medicare drug coverage since 2006. The $2,000 cap is live in 2026 — anyone with expensive drugs saves money directly.

2027 Advance Notice — 2027 MA/Part D Advance Notice — Key Changes

Rate CMS projects a 4.33% increase in the national average MA benchmark for 2027. Key changes: HCC V28 risk adjustment model expansion to full weight, elimination of the HCC V24 blended period, and updated SNP enrollment growth assumptions.

TL;DR: Plans bidding for 2027 can expect 4.33% more revenue. But HCC V28 recoding changes who gets paid what — plans with sicker populations should model carefully.