On January 26/27, 2026, the big news was that CMS has announced there is virtually no change in rates for Medicare Advantage in CY 2027. They issued a press release, FAQ sheet, and a 160-page policy document. Reader here for Reuters. Or see picture for the main takeaway:
But wait a second - back on November 28, 2026, they issued a 137-page Proposed Rule for Medicare Advantage in 2027.
How to do the policy making processes differ?
I asked Chat GPT.
### SUMMARY OF THE TWO DOCUMENTS
- CMS released two different CY 2027 “Part C & D” documents, but they serve separate legal functions — one changes program rules, the other updates payment mechanics.
- The November 2025 Federal Register Proposed Rule (CMS-4212-P) is formal regulation. It amends the Code of Federal Regulations and covers policy areas such as Star Ratings methodology, marketing and TPMO oversight, enrollment processes, SNP policies, and Part D benefit redesign. This rule determines what Medicare Advantage and Part D plans must do operationally. It will later become a Final Rule.
- The January 26, 2026 Advance Notice is not a regulation. It is an annual payment methodology notice required by statute. It updates MA benchmarks, growth rates, risk adjustment models (CMS-HCC and RxHCC), normalization factors, coding intensity adjustments, and Part D benefit parameters. It determines how CMS calculates plan payments, and becomes the April Rate Announcement, not a Final Rule.
###
### LINKS
Fed Reg November 2025 here.
Advanced notice 160pp January 2026 here. Fact sheet here. January 2026 press release here.
###
###
You are absolutely justified in being confused — CMS uses two totally different legal pipelines that both talk about “Part C & D changes for 2027,” but they do different jobs.
Here’s the clean mental model.
🧠You are looking at two separate rulemaking universes
| November 28, 2025 document | January 26, 2026 document |
|---|---|
| Federal Register Proposed Rule (137 pages) | Advance Notice (160 pages) |
| Docket: CMS-4212-P | Not a FR rule — payment notice under SSA §1853 |
| Amends regulations (42 CFR Parts 422 & 423) | Updates payment formulas, rates, and risk models |
| Becomes a Final Rule later | Becomes the Rate Announcement (April 2026) |
| Legal authority: APA rulemaking | Legal authority: MA rate-setting statute |
| Changes program rules | Changes how plans get paid |
📘 1. The NOVEMBER rule = PROGRAM POLICY RULE
This is a classic CMS regulation. It changes the rules of the game.
It covers things like:
Part D benefit redesign codification (IRA changes)
Star Ratings methodology changes
Marketing / TPMO oversight
Enrollment rules
SNP policy
MLR / reporting ideas
Network adequacy process changes
It literally amends the CFR.
This is about what plans must do.
Source: The November rule states it revises “Part C and Part D regulations” and includes policy areas like Star Ratings, marketing, enrollment, and drug coverage.
2025 CMS 1128 90FR54894 137p Pr…
👉 Outcome: Final Rule later in 2026.
💰 2. The JANUARY document = PAYMENT & RISK ADJUSTMENT NOTICE
This one is not a regulation. It does not amend the CFR.
It exists because the Medicare statute requires CMS to annually publish:
MA growth rates
Benchmarks
Risk adjustment model updates (CMS-HCC, RxHCC)
Coding intensity adjustment
Normalization factors
Part D benefit parameters
Payment methodology details
It is explicitly called:
“Advance Notice of Methodological Changes for CY 2027 MA Capitation Rates and Part C and Part D Payment Policies”
2026 CMS 0126 Part C D 2027 Pro…
This is about how CMS calculates plan payments, not beneficiary rules.
👉 Outcome: Becomes the Rate Announcement (April 6, 2026), not a Final Rule.
🔑 The Key Distinction
| Topic | Lives in November Rule? | Lives in January Notice? |
|---|---|---|
| Marketing restrictions | ✔ | ✖ |
| TPMO oversight | ✔ | ✖ |
| SNP eligibility policy | ✔ | ✖ |
| Part D benefit structure (legal codification) | ✔ | ✖ |
| MA benchmark math | ✖ | ✔ |
| Risk adjustment model calibration | ✖ | ✔ |
| Coding pattern adjustment | ✖ | ✔ |
| Star Ratings payment impact | ✖ (policy only) | ✔ |
| Part D risk model updates | ✖ | ✔ |
🎯 Why CMS does this (historical reason)
Medicare Advantage has two separate legal mechanisms:
A. Program rules
Made through APA rulemaking → CFR changes
(That’s your November document)
B. Payment formulas
Made through annual rate notice → Actuarial / statutory process
(That’s your January document)
This split goes back to the Medicare Modernization Act (2003) and earlier managed care law. MA payment is treated like insurance rate-setting, not standard rulemaking.
⚠️ Why it feels overlapping
Both documents mention:
Star Ratings
Part D
Risk adjustment
“Part C and D policies”
But:
November = WHAT the program requires
January = HOW CMS calculates money
Example:
November rule: May change Star Ratings measure set.
January notice: Applies Star Ratings to determine bonus percentages in benchmarks.
Different step in pipeline.
🧠Think of it like this
| Stage | Document |
|---|---|
| Rules of football | November Proposed Rule |
| How the referee calculates the score | January Advance Notice |
📌 Final takeaway
You are not seeing two competing proposed rules.
You are seeing:
1️⃣ Policy rulemaking (regulations)
2025 CMS 1128 90FR54894 137p Pr…
2️⃣ Annual payment methodology notice (actuarial rate process)
2026 CMS 0126 Part C D 2027 Pro…
They run in parallel every year and converge when plans bid.
If you’d like, next I can:
A) Map how a single issue (like Star Ratings) flows through BOTH pipelines
B) Show which parts of the January notice plans actually care about most
C) Explain how Part D IRA changes appear in each document
Your confusion = totally rational. CMS’s architecture is… vintage 1997 managed care law meets modern Medicare.
#######
Biden year 4 Med Adv policymaking had many pages about insuring coverage parity, e.g. validity of LCDs in Part C. Trump Admin went radio silent. No change, I assume?
####
Short answer: No — neither document meaningfully addresses traditional coverage policy (NCDs, benefit categories, Part A/B service definitions, or Part C “same benefit” scope issues).
You’re picking up on a real shift.
📘 November Proposed Rule (CMS-4212-P)
This rule is about MA/Part D program operations, not Medicare coverage law. Its focus areas are:
Part D benefit redesign mechanics
Star Ratings methodology
Marketing / TPMO oversight
Enrollment and SNP policy
Reporting, MLR, network adequacy processes
It amends 42 CFR 422 & 423, but does not reopen:
National Coverage Determinations (NCDs)
“Reasonable and necessary” standards
Part A vs Part B benefit definitions
MA “uniformity” or “same benefit as FFS” doctrine in any substantive way
Even the IRA Part D sections are benefit design financing, not coverage scope.
Source: The rule’s purpose is described as revising MA and Part D regulations on Star Ratings, marketing, enrollment, drug benefit structure, etc. — not coverage policy.
💰 January Advance Notice
This one is even further removed. It is a payment mechanics document:
Benchmarks
Growth rates
Risk adjustment models
Coding intensity adjustment
Part D bid parameters
It explicitly describes itself as updating capitation rates and risk models, not benefits.
No discussion of:
Coverage standards
Clinical benefit categories
Concordance with FFS NCDs
Scope of Part A/B services
🎯 What’s changed vs prior CMS eras
You’re right — prior administrations (especially 2021–2024) used MA rulemaking to discuss:
Guardrails around MA “reinterpretation” of coverage
FFS-equivalence expectations
Clinical evidence standards
Prior auth alignment
That language is largely absent here. The focus is:
Program integrity, payment calibration, and administrative simplification
not
Clinical coverage policy
🧠Bottom line
| Topic | November Rule | January Notice |
|---|---|---|
| NCDs | ❌ | ❌ |
| Part A/B benefit definitions | ❌ | ❌ |
| “Reasonable and necessary” | ❌ | ❌ |
| MA must mirror FFS benefits | Only background law, not policy | ❌ |
| Coverage expansions or restrictions | ❌ | ❌ |
These documents operate in the MA/Part D administrative and financial domain, not the Medicare coverage doctrine domain.
Your observation = correct: coverage policy discussion has moved offstage in these CY 2027 materials.
