I know, I know. It seems like you just reviewed Medicare plans to find the best one for 2025. Believe it or not, it’s time to do it again. To prepare for the annual Medicare Open Enrollment period that runs October 15-December 7, don’t forget to look at these seven changes that begin in 2026.
1. Prescription payment plans
2025 was the first year that the Medicare Prescription Payment Plan (MPPP) let people pay for their drugs over the course of the calendar year rather than pay every time they filled a prescription.
Beginning in 2026, if you participate in the MPPP, you’ll be automatically re-enrolled the following year unless you opt out. Also, a separate renewal notice will be sent after the end of the annual election period and include the payment plan’s upcoming terms and conditions.
If you decide to opt out, Centers for Medicare and Medicaid Services (CMS) will require plan sponsors to process your request within three calendar days.
2. The cap on Part D prescription drug expenses goes up
In 2026, the cap on out-of-pocket prescription drug costs will be indexed for inflation. That means the out-of-pocket maximum will be $2100, rather than the $2,000 cap in 2025.
3. Medicare Part D deductible is going up
For Part D prescription drug plans with a deductible, the annual maximum is going up. In 2025 the cap is $590. In 2026 that increases to $615.
If your plan has a deductible, you pay all out-of-pocket costs until you meet your plan’s full deductible. After that, you’ll pay 25% coinsurance for both generic and brand-name drugs. This continues until your total out-of-pocket spending on covered Part D drugs reaches $2,100 for 2026.
4. Limit on special supplemental benefits for the chronically ill (SSBCI) on Medicare Advantage
For people with Medicare Advantage (MA) plans the Centers for Medicare and Medicaid Services (CMS) finalized a list of supplemental benefits that won’t be covered under the Special Supplemental Benefits for the Chronically Ill (SSBCI) category.
The CMS classifies the items on the list as “non-primarily health-related items or services” that do not meet the standard of having a reasonable expectation of improving or maintaining the health or overall function of the enrollee. For example:
- Alcohol
- Tobacco
- Cannabis products
- Non-healthy food
- Life insurance
- Hospital indemnity insurance
- Funeral planning and expenses
- Procedures that are solely cosmetic in nature and do not extend upon Traditional Medicare coverage
- Broad membership programs inclusive of multiple unrelated services and discounts
5. Insulin costs capped
Since 2023, the cost of insulin for Medicare beneficiaries has been capped at $35 per month. Beginning in 2026 the cap will be the lesser of:
- $35
- 25% of the maximum fair price established for the covered insulin product under the Medicare Drug Price Negotiation Program
- 25% of the negotiated price of the covered insulin product under the stand-alone Medicare prescription drug plan (PDP) or MA plan with prescription drug coverage (MA-PD plan)
6. Zero cost-sharing for adult vaccines
Medicare beneficiaries have had access to a limited number of free vaccines since 2023. However, free vaccines are now a permanent feature of Medicare Part D plans. Part D insurers must continue to waive deductibles and cost-sharing for adult vaccines recommended by the Advisory Committee on Immunization Practices (ACIP).
The list of free vaccines is updated every year, so just because a vaccine is on the list this year doesn’t mean it will be next year. If you plan on traveling outside the country, the CDC suggests that you make sure you are up to date with all of your routine vaccines.
7. Prior authorizations for traditional Medicare are coming to six states
Original Medicare Parts A and B have historically required very few pre-authorizations in order to provide service. Pre-authorizations were predominately required if you had a Medicare Advantage plan. That changes next year.
In 2026, CMS will begin using AI in the pre-authorization process. CMS expects AI to sniff out unnecessary and inappropriate care which translates into saving money. New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington will begin using the Wasteful and Inappropriate Service Reduction (WISeR) Model to perform prior authorization evaluations.
CMS wants you to know that AI won’t decide if a procedure is approved or denied. Real people will review the information and make the final call.
Review your Medicare plan annually
The upcoming Medicare Open Enrollment period is your opportunity to change plans; join, switch, or drop a Medicare Advantage Plan or Medicare Part D drug plan, switch to Original Medicare, or keep your current coverage. And if you’ve reviewed your options and you’re happy with your current coverage, you don’t need to do anything. But you need to check your coverage to make sure. Don’t let time get away from you and find too late that there was a better plan.
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