Big Changes Coming to Medicare

As we head into the final stretch of Medicare Open Enrollment (now through December 7), we’re spotlighting Medicare Advantage (Part C) and Medigap (Supplement)—the areas with the most plan-by-plan adjustments for 2026—and summarizing key Part B and Part D updates to factor into your decision.

What’s Changing—and Why It Matters

Medicare Advantage (Part C)

• Extras tightening: Some plans are scaling back add-ons like OTC allowances, transportation, and dental/vision perks—such as reducing quarterly OTC card amounts or lowering dental annual maximums.
• Prior authorization: Expect stricter rules and new pilot programs; services like advanced imaging, infused medications, or certain therapies may face added approvals or step-therapy requirements.
• Networks & access: Doctor, hospital, and pharmacy networks can shift; a preferred specialist or hospital may no longer be in-network, and MA-PD plans may change their preferred pharmacy tiering.
• Total cost vs. premium: Look beyond the monthly premium to copays/coinsurance, MOOP (maximum out-of-pocket), drug tiers, and referrals—low-premium plans can still lead to higher annual costs if you need frequent care or brand-name drugs.
• Star ratings & service: If a plan’s rating drops (e.g., from 4★ to 3.5★), you may see leaner supplemental benefits or less robust member support.

Medigap (Supplement to Original Medicare)

• Stable benefits, variable pricing: Plan letters (e.g., G) are standardized, but premiums and rate increases vary by insurer and state—two Plan G policies can differ significantly in monthly cost.
• Underwriting considerations: Moving from MA to Medigap may require medical underwriting outside guaranteed-issue windows; applications can include health questions or waiting periods for pre-existing conditions.
• Predictability & freedom: Many choose Medigap for predictable cost-sharing and broad national access to any provider who accepts Medicare—helpful if you travel frequently or see out-of-state specialists.

Don’t Forget: Part B & Part D Changes for 2026

Medicare Part B

• Monthly premium: increasing from $185 to $206.50 (+$21.50/month).
• Annual deductible: rising from $257 to $288.
• IRMAA (income-related surcharges): Higher-income beneficiaries may pay more; if your income declined due to a qualifying life event (such as retirement), you can request a reassessment via SSA-44.

Medicare Part D (Prescription Drug Plans)

• Out-of-pocket cap: $2,100 for the year, after which covered drugs should be $0 for the remainder of 2026.
• Deductible: $615 before standard copays/coinsurance apply on many plans.
• Premiums: expected to rise by ~6% on average.
• Drug price negotiations: Select high-cost medications may trend lower over time; check your plan’s 2026 formulary for tier or authorization changes.

Your 6-Point Checklist Before Dec 7

1. Review your 2026 Evidence of Coverage (EOC): Note changes to networks, prior authorization, copays, MOOP (MA), and extras—such as dental maximums, eyewear allowances, and transportation ride limits.
2. Confirm providers: Verify that your PCP, specialists, hospitals, and (for MA-PD) your preferred pharmacy are in-network for 2026.
3. List your medications: Check tiers, prior authorization/step-therapy rules, and monthly costs under 2026 formularies.
4. Compare “all-in” costs: Add premium, deductible, expected copays/coinsurance, and MOOP (MA) versus Medigap premium plus standalone Part D. Consider both typical-use and higher-use scenarios.
5. Check IRMAA exposure: If you’re near a threshold, model total Part B & D premiums with surcharges and assess whether an appeal is warranted.
6. If switching to Medigap: Confirm state-specific underwriting and effective dates; don’t cancel existing coverage until the new policy is approved and active to avoid gaps.

Helpful Resources

• Find local Medicare specialists: Medicaresupp.org (use the ZIP-code finder to compare MA-PD versus Medigap Plan G plus Part D).
• “Medicare & You 2026” handbook: Use SHIP hotlines (starting on page 114) for free, unbiased help comparing options.
• New to Medicare? Understanding Medicare Choices (Vanguard) offers a clear overview to help you choose between MA and Original Medicare with Medigap.

If you use any of these resources, we’d love your feedback—what worked well, what didn’t, and any surprises you found. Your experience helps us guide others more effectively.