🚨 Six Key Medicare Changes Coming in 2026: What You Should Know

Medicare is rolling out important updates for 2026—and your coverage and out‑of‑pocket costs could be affected. Based on recent reporting from Kiplinger, here’s a summary of the most significant changes all Medicare beneficiaries need to know:

1. Automatic Enrollment in the Medicare Prescription Payment Plan (MPPP)

Starting in 2026, if you’re enrolled in the MPPP, you’ll be automatically re-enrolled each year unless you opt out. A separate renewal notice will detail your plan terms and you’ll have up to three calendar days to request an opt‑out—up from the previously proposed 24‑hour window.

2. Part D Drug Out‑of‑Pocket Cap Rises to $2,100

The annual maximum you can spend on prescription drugs under Part D will increase by $100—from $2,000 in 2025 to $2,100 in 2026—and will continue to adjust annually for inflation.

3. Insulin Cost Cap Remains $35/Month

Insulin will continue to be capped at $35 per month, with no deductible applied. This cost cap becomes a recurring annual entitlement starting in 2026.

4. Adult Vaccines Continue to Be Free

Vaccines recommended by the Advisory Committee on Immunization Practices (ACIP)—such as shingles, pneumonia, and flu shots—will still be available at zero cost under Medicare Part D, with no deductible or co-pay.

5. New Restrictions on Supplemental Benefits for Chronically Ill (SSBCI)

Medicare Advantage plans that provide extra benefits for chronically ill enrollees will now be limited. A finalized rule clearly defines non‑allowable “non‑health‑related” supplemental services—plans can no longer offer items or services that don’t reasonably maintain or improve health outcomes.

6. Prior Authorization Required Under Original Medicare in Six States

Beginning January 1, 2026, traditional Medicare (Parts A and B) will require prior authorizations in six states: New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington through CMS’s AI‑supported WISeR model. A licensed clinician will make final determinations, but the process aims to reduce unnecessary or inappropriate services.

🎯 What These Changes Mean for You

• The MPPP automatic re-enrollment may offer cost-smoothing benefits—just be ready to opt out quickly if needed.

• The Part D cap rising to $2,100 still provides strong protection—but it’s important to plan for higher maximum drug costs next year.

• Insulin users and those needing adult vaccines continue to benefit from consistent protections.

• If you're on a Medicare Advantage plan that offers SSBCI benefits, check whether your plan will still offer the same extras in 2026.

• Residents of the six states approved for WISeR should talk to providers about how prior authorization may impact scheduling and access to care.

✅ What You Should Do Next

1. Review your Medicare coverage annually. Use the October 15–December 7 open‑enrollment period to evaluate if your Part D or Medicare Advantage plan still fits your needs.

2. Track new costs and benefit changes. Even small changes in caps and cost‑sharing can add up.

3. Contact me or your local insurance agent if you need help comparing plans in your area—we are advisers who offer unbiased assistance.