Medicare Advantage News: What the 2026 Payment Increase Means for Medical Practices

The Centers for Medicare & Medicaid Services (CMS) has finalized updates to the 2026 Medicare Advantage (MA) payment policy. With diabetic populations on the rise and preventive care gaining policy traction, these changes have far-reaching implications for healthcare providers. Keep reading to learn what these updates mean for your practice’s operations, compliance strategy, and long-term growth.

Understanding the 2026 CMS Payment Update

In April 2025, CMS announced a 3.7% average increase in revenue for Medicare Advantage (MA) plans, totaling a $16 billion funding boost. In light of this, the 2026 CMS rate announcement includes an average increase of roughly 5% in government payments to MA plans. 

While this increase is largely welcomed, many clinical stakeholders have voiced concern over potential administrative burdens and gaps in physician compensation due to ever-rising costs for providing care. 

Despite the mixed reception, the implications of this payment increase for primary care providers is significant. With increased funding and renewed focus on value-based care, the potential for better reimbursements for eye care practices is increased—and with it, the pressure to rigorously document, screen, and close care gaps.

How Medicare Advantage News Impacts Eye Care

Expanded Access and Workflow Optimization

More MA funding translates to stronger reimbursement potential for practices that provide high-quality, preventive care. This potential is a double-edged sword though—while the potential for care is increased, the path to receiving prior authorization for that care may become more difficult. The solution to this potential roadblock is consistent, highly accurate, and compliant documentation. Another way to approach this challenge is to avoid the need for advanced intervention whenever possible through thorough, high-quality preventive care. 

An example of this is how IRIS serves primary care clinicians and home healthcare providers. The IRIS solution allows for diabetic retinopathy screenings, which is the leading cause of preventable blindness in U.S. adults. This use of fundus cameras enables image capture by non-specialist staff and seamless EMR integration, helping practices expand their care capabilities without overloading clinical teams. 

When organizations are able to incorporate proactive, preventive care, they benefit from early documentation and record-keeping, as well as a reduced number of patients who need more advanced and costly interventions. 

Preventive Screenings

CMS’s priority for preventive care places greater emphasis on providers for early diabetic eye disease detection. Since non-proliferative diabetic retinopathy (NPDR) screenings are a crucial form of preventive care for patients with diabetes, this is one area where providers can align their care priorities with incentives from CMS. Timely screenings for diabetic retinopathy are so crucial because they reduce the likelihood of expensive interventions like vitrectomy surgery (IRIS Blog on Vitrectomy).

NPDR often presents no symptoms, and the disease is only noticeable once long-term damage has already occurred, which makes proactive screening essential. If diabetic retinopathy is detected after further progression, expensive interventions like a vitrectomy surgery are often necessary. Tools like IRIS increase access to screenings through primary care and home healthcare settings, so the disease can be caught early when treatment is most effective.

HEDIS and Star Ratings: A Strategic Focus

HEDIS measures and CMS Star ratings are key drivers of Medicare Advantage plan performance and revenue. Much like Medicare Advantage payment amounts, HEDIS measures are updated annually. These changes often have a direct impact on providers caring for patients with diabetes and other conditions that rely heavily on preventive care to ensure optimal quality of life as they manage the disease. 

2025 HEDIS Updates

One critical HEDIS measure is the annual diabetic retinal exam. In 2025, this measure transitioned to administrative-only reporting, meaning electronic documentation is required to be submitted directly to a health organization for every exam report. 

Organizations with poor HEDIS performance risk losing millions in bonus payments. For example, an organization with a 100,000-member plan could qualify for $17 million annually by improving compliance for every quality measure taken.

Star Ratings 

Star ratings are another way to measure accessible and preventive care. This rating system pertains specifically to Medicare Advantage plans and is focused specifically on outcomes related to overall patient health, experience, and access to care. Because of its portability and ease of use for primary care and in-home healthcare providers, IRIS is a solution that helps healthcare organizations meet all of these objectives, while also meeting compliance standards and simplifying reporting. 

Risk Adjustment and RAF Scores: Financial Impact Beyond Compliance

The 2026 CMS rate announcement also correlates with ongoing changes to the Hierarchical Condition Category (HCC) model, now in Version 28. Accurate documentation of diabetic conditions like diabetic retinopathy directly boosts Risk Adjustment Factor (RAF) scores for increased plan reimbursements. Diabetes and diabetes-related conditions carry significant weight in RAF scoring, and as medical providers seek to increase their RAF scores for more accurate Risk Adjustment payments, IRIS is an ideal solution. 

When individuals with diabetes are not screened for diseases like diabetic retinopathy, their risk of living with an undetected, vision-threatening disease is multiplied. In turn, healthcare providers risk losing reimbursements due to a lack of accurate patient data, which will only prove detrimental in the long run, as these patients will eventually need far more invasive and cost-draining services to treat their proliferative diabetic retinopathy. 

IRIS improves RAF score capture by creating a reliable and accessible screening opportunity, so that undiagnosed diabetic retinopathy cases can be identified. This drives both patient outcomes and financial performance.

Leveraging MA Changes to Improve Retinal Screening Compliance

For practices looking to adapt to the new MA landscape, leveraging in-office and mobile retinal screenings can be a game-changer. IRIS supports in-home care organizations and field-based teams with lightweight, portable equipment and high-gradeability performance, allowing screenings to be done wherever patients are.

Teleretinal solutions like IRIS reduce friction and increase screening rates across underserved populations, directly supporting MA plan goals for accessibility, compliance, and risk adjustment accuracy.

The 2026 MA Model: Next Steps for Providers

Balancing changes to Medicare Advantage can be overwhelming, as well as keeping track of HEDIS ratings, Star ratings, and RAF scores for your practice. 

It’s important to remember that providing practical, preventive care day in and day out is the path to sufficient reimbursement and good standing among organizations like CMS. One step that can be taken for operational success and long-term outcomes is the IRIS solution, which is:

• Designed for preventive impact: Enabling earlier detection and intervention for NPDR
• Built for reporting ease: Structured data outputs for HEDIS and risk adjustment
• Partnered for ROI: Supporting higher Star ratings and financial incentives

Explore how IRIS can transform your diabetic eye screening approach with more readable exams, seamless data integration, and ongoing support.

FAQs

What is the 2026 CMS Medicare Advantage news? 

CMS increased MA plan payments by an average of 5% in 2026, with updated risk adjustment models and a focus on preventive care.

How does this Medicare Advantage news affect primary care practices?

More funding means higher potential reimbursement for documented preventive services like diabetic retinal screenings.

What is the role of IRIS in this landscape?

IRIS enables high-quality, compliant DR screenings that support HEDIS reporting, risk adjustment, and care gap closure.

What is NPDR and why is it important?

Non-proliferative diabetic retinopathy is the earliest stage of diabetic retinopathy. Early detection via screening prevents costly complications and treatments. 

How do diabetic retinopathy screenings influence HEDIS and RAF scores?

They close documented care gaps and improve data capture for risk adjustment, directly impacting revenue and compliance.

 

---

 

SM 207, Rev A