Medicare Advantage plans offer beneficiaries an alternative to traditional Medicare, often providing coverage that encompasses a broader range of services. This flexibility was expanded by the Bipartisan Budget Act of 2018, which permitted Medicare Advantage plans to include benefits unrelated to direct health care as long as they aid in maintaining or improving functional capacity for individuals managing chronic conditions.
Following this legislative adjustment, various Medicare Advantage plans proposed coverage for additional ancillary services to the Centers for Medicare and Medicaid Services (CMS). However, CMS has taken a firm stance against approving certain proposed services, emphasizing the need for direct health benefits or maintenance of overall function.
In a recent development, effective starting in 2026, CMS has codified a rule barring Medicare Advantage plans from including coverage for an array of procedures deemed cosmetic in nature. Specifically, CMS highlighted previous rejections of proposals to cover services such as botulinum toxin injections intended solely for aesthetic enhancements like reducing wrinkles and facial lines. According to CMS, such purely cosmetic procedures do not meet the criteria reasonably expected to improve or sustain the enrollee's health or overall functional abilities.
The procedural exclusions enumerated in the updated Section § 422.102 include:
- Cosmetic surgeries, such as facelifts
- Procedures targeting facial lines for aesthetic purposes
- Treatments addressing the atrophy of collagen and fat with cosmetic intent
- Cosmetic interventions aimed at mitigating bone loss resulting from aging
The American Society of Plastic Surgeons has reported a significant rise in cosmetic surgical procedures among individuals aged 55 and over, citing an estimated 4.1 million seniors undergoing such interventions—a 28% increase compared to 2010 figures. Given the CMS ruling, Medicare Advantage plans may no longer provide coverage for these types of procedures, potentially affecting retirees who wish to pursue them.
This regulatory change places increased responsibility on seniors to manage personal finances prudently to afford cosmetic procedures not covered by their Medicare Advantage plans. The restriction underscores the importance of strategic financial planning, including sufficient savings and investments, to cover health-related needs not encompassed by current Medicare provisions.