Episode 3: Medicare Final Rule 2026 | AI, Weight Loss Drugs & Prior Authorizations Under Scrutiny

Jessica Zeff
Jul 1
3 min read

The healthcare regulatory landscape is always evolving, and keeping up with changes—especially in Medicare—is crucial for compliance professionals. As of January 1, 2026, new Medicare guidelines are set to take effect, bringing a mix of clarity, continued uncertainty, and opportunities to improve patient care. Understanding the key updates, what was left out, and how to manage these changes proactively can help compliance teams support their organizations more effectively.

The Ongoing Challenge of AI in Medicare Compliance

Artificial intelligence (AI) continues to be a disruptive force across healthcare, promising improvements in efficiency and decision-making. Yet, despite its growing adoption, the recent Medicare final rule did not include clear guidelines on AI usage. This absence leaves organizations in a gray area, struggling with questions about ethical implementation, transparency, and accountability.

AI can assist compliance in numerous ways—automating routine tasks, analyzing large data sets to detect fraud or non-compliance, and even supporting patient care decisions. However, without defined parameters from Medicare, the risk of misapplication or regulatory scrutiny remains high.

Compliance teams must therefore remain vigilant and cautious when integrating AI tools into Medicare-related workflows. Investing in staff training around AI’s ethical use and fostering a culture of human oversight will be key to navigating these uncertainties.

What Was Left Out of the Medicare Final Rule?

Several high-profile topics that many expected to be addressed in the 2026 Medicare rule were notably absent, leaving compliance professionals with unresolved questions:

AI Usage Guidelines: Despite AI’s growing role in healthcare, Medicare’s final rule provides no concrete framework for its ethical use within compliance or patient care.
Coverage for Anti-Obesity Medications (AOMs): Part D coverage still excludes weight loss drugs, despite evidence that these medications can help manage comorbid conditions such as diabetes and heart disease.
Prior Authorization Requirements: There remains no new clarity on prior authorization processes, particularly around HealthEquity by item or service, complicating administrative workflows and potentially impacting patient access.

These omissions create a degree of uncertainty for organizations trying to align with Medicare’s expectations and deliver compliant care.

Positive Developments: Enhancing Access and Affordability

Despite some gaps, the final rule introduces important changes aimed at reducing barriers to care and improving patient outcomes. Notable positive updates include:

Elimination of Cost Sharing for Adult Vaccines: Beneficiaries can now receive adult vaccines without out-of-pocket costs, a major step forward in preventive care.
Capping Cost Sharing for Insulin: The cost for a one-month supply of insulin is capped, easing financial burdens for individuals managing diabetes.
Expanded Behavioral Health Provider Coverage: Medicare Advantage plans will now cover a broader range of behavioral health providers, such as marriage and family therapists and mental health counselors, improving access to mental health services.

These enhancements reflect a growing emphasis on holistic and equitable healthcare delivery.

Strategies for Compliance Professionals: Managing Change Proactively

To effectively handle these shifts and ongoing uncertainties, compliance professionals should adopt a proactive, collaborative approach:

Education and Communication: Regularly inform stakeholders through town halls, department meetings, and targeted updates. Break complex regulations into understandable segments to facilitate smoother implementation.
Project Management and Collaboration: Develop clear timelines and involve cross-department teams to address challenges and ensure alignment.
Networking and Knowledge Sharing: Engage with peers in the compliance community to share insights, interpretations, and best practices.

Summary of Key Points for Compliance Teams

Medicare’s 2026 final rule leaves several key questions unresolved, especially concerning AI usage, weight loss medication coverage, and prior authorization policies.
The elimination of vaccine cost sharing and insulin cost caps provide meaningful relief and improved care access for beneficiaries.
Expanded coverage of behavioral health providers aligns with broader healthcare trends emphasizing mental health.
Staying informed and fostering collaboration within your organization and the wider compliance community is critical to navigating this evolving environment.

Conclusion

The Medicare regulatory landscape is shifting, bringing both opportunities and challenges for compliance professionals. While important advancements in patient access and affordability have been made, significant gaps—particularly around AI and prior authorization—require careful attention and strategic planning.

Compliance teams play a vital role in guiding their organizations through these changes. By focusing on education, clear communication, collaborative project management, and leveraging professional networks, compliance professionals can help their organizations stay compliant and support high-quality patient care.

As the healthcare landscape continues to evolve, remaining adaptable and proactive is the best way to turn regulatory shifts into opportunities for improvement.

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