Medicare Advantage Changes in 2026: What You Really Need to Know

There’s a lot of noise out there about Medicare Advantage in 2026. You may have even seen headlines about a “5.06% CMS payment boost.” Honestly? That number matters to insurance companies, not to you. What matters to you is:

• Will my plan still be available?
• Will my doctor and pharmacy stay in-network?
• How much more am I going to pay in 2026?

I’ll break down the big changes — in plain English — and tell you what steps to take so you’re ready for open enrollment.

Medicare Advantage isn’t going away. But plans are shifting, shrinking, and in some cases disappearing. Here’s why:

• More government money flowing into MA plans (5.06% average increase = about $25 billion system-wide).
• Stricter rules on prior authorization — plans have to honor hospital approvals through discharge and speed up decision times.
• Caps and guardrails on “extra” benefits like meals, transportation, and chronic-condition perks.
• Part D drug changes — higher deductible, new $2,100 annual out-of-pocket cap, plus $35 insulin and free vaccines under the Inflation Reduction Act.
• Some big insurers scaling back service areas or dropping plans in certain counties.

Translation? You’ll have fewer choices in some places, different rules in others, and new costs to pay attention to.

One of the top complaints I hear is about prior authorization — when your plan makes you get approval before covering care. In 2026, rules tighten:

• Approvals for inpatient care must last until discharge (no more re-approving mid-stay).
• Plans have to respond faster — 14 business days for most services.
• Denials must come with a clear, clinical reason.
• You get expanded rights to appeal, including an independent external review.

This means less red tape for you and your doctor — but it also means you’ll want to read denial letters carefully, since appeals now have more teeth.

Plans often market perks like rides, grocery cards, or in-home support. Starting in 2026, CMS is requiring insurers to:

• Clearly document which chronic conditions qualify you for those extras.
• Stick to standardized benefit categories (like nutrition or transportation).
• Cap spending on these benefits so they don’t crowd out core medical coverage.

That means fewer “surprise” perks and more consistency — but also fewer bells and whistles in some plans.

This is where almost everyone feels the change:

• Deductible: $615 (up from $590 in 2025).
• Annual out-of-pocket cap: $2,100 (up from $2,000 in 2025).
• Insulin: Still capped at $35/month, with no deductible.
• Vaccines: Still $0 out of pocket for ACIP-recommended adult vaccines.

Good news: once you hit the $2,100 cap, you’re done paying for covered prescriptions that year. Bad news: costs are still trending up, so you’ll want to check your plan’s formulary closely.

This is the headline not enough people are paying attention to. Several large insurers are quietly trimming their Medicare Advantage offerings for 2026.

I’m hearing about:

• Plans being discontinued in multiple states.
• Networks narrowing in certain metro and rural areas.
• Service areas shrinking where profitability or provider access is a challenge.

What this means for you: your plan might not be available next year — or it might cover fewer doctors and hospitals. Even if you don’t get dropped, you could see narrower choices.

Here’s your action plan heading into fall 2025 open enrollment:

1. Don’t assume your plan stays the same. Read your Annual Notice of Change letter line by line.
2. Check your doctors and pharmacies. Make sure they’ll still be in-network.
3. Review your prescriptions. See if any drugs got dropped or bumped to a higher tier.
4. Compare alternatives. Use Medicare.gov’s Plan Finder to see what else is available in your county.
5. Consider Original Medicare with a Medigap policy. In some cases, it may give you more stability and predictability than Medicare Advantage.

• Oct. 15 – Dec. 7, 2025: Annual Enrollment Period (AEP) to join, switch, or drop Medicare Advantage or Part D.
• Jan. 1 – Mar. 31, 2026: Medicare Advantage Open Enrollment — one more chance to switch plans or go back to Original Medicare.
• Special Enrollment Periods: Triggered by things like moving or losing employer coverage.

Medicare Advantage isn’t “ending” in 2026 — but it is changing in ways that could hit your wallet and your access to care. Don’t wait until December to scramble. Get ahead of it, review your options early, and line up the coverage that works for your health and your budget.