What Are the 2026 Changes to Medicare?

Medicare is undergoing significant changes in 2026 that will directly impact your healthcare costs, coverage options, and access to care. As we approach the new year, you need to understand these upcoming modifications to make informed decisions about your Medicare coverage. Whether you're currently enrolled in Original Medicare, Medicare Advantage, or considering your options, these changes will affect your out-of-pocket expenses and available benefits.

At Borde & Associates, we've been helping families navigate Medicare changes for over a decade, and we're here to guide you through what promises to be one of the most substantial years of Medicare updates in recent history. Let's break down exactly what you can expect and how these changes might benefit or impact your specific situation.

Major Prescription Drug Cost Changes Coming Your Way

Out-of-Pocket Spending Caps Adjustment

Your annual out-of-pocket maximum for Part D prescription drugs will increase to $2,100 in 2026, up from the current $2,000 cap in 2025. While this represents a $100 increase, you're still protected by a cap that didn't exist just a few years ago. This change means once you reach $2,100 in prescription drug costs, Medicare covers 100% of your remaining prescription expenses for the year.

Additionally, the Part D deductible is rising to $615 per year in 2026. This means you'll pay the first $615 of your prescription drug costs before your Medicare Part D coverage begins to help with expenses.

Historic Medicare-Negotiated Drug Prices

Starting January 1, 2026, you'll benefit from Medicare's first-ever negotiated lower prices for 10 high-cost prescription medications. These drugs include treatments for:

• Arthritis and inflammatory conditions
• Blood clots and cardiovascular issues
• Various cancer treatments
• Diabetes management

This groundbreaking price negotiation is expected to reduce your out-of-pocket spending by an estimated $1.5 billion collectively in 2026, with savings continuing every year afterward. If you're currently taking any of these medications, you could see substantial reductions in your monthly prescription costs.

Enhanced Vaccine and Insulin Coverage

Your Medicare coverage will expand to include free recommended adult vaccines with no deductible or co-pay requirements. This includes:

• Shingles vaccines
• Pneumonia vaccinations
• Annual flu shots
• Other CDC-recommended adult immunizations

For insulin users, your monthly costs will be capped at $35 or 25% of the negotiated drug price, whichever amount is lower. This protection ensures you won't face unexpected spikes in insulin costs throughout the year.

Premium and Deductible Changes You Should Expect

Medicare Part B Premium Increases

Your Medicare Part B premium will see a significant increase in 2026. The average monthly premium is projected to rise from $185 in 2025 to $206 in 2026: representing a 12% increase that's roughly twice as high as the previous year's adjustment.

This premium increase affects everyone enrolled in Medicare Part B, and you'll see this change reflected in your Social Security deductions or quarterly billing statements.

Part A Cost Adjustments

While most Medicare beneficiaries don't pay premiums for Part A, those who do will see increases to either $310 or $563 per month in 2026, depending on your work history and quarters of coverage.

The Part A deductible will also increase to $1,716 for 2026, compared to $1,676 in 2025. This deductible applies each time you're admitted to the hospital as an inpatient.

Medicare Advantage Plan Landscape Changes

Plan Availability Shifts

You'll notice significant changes in Medicare Advantage plan availability in 2026. Major insurers, including UnitedHealthcare: the largest Medicare Advantage provider: are withdrawing from certain markets. This means your current plan might not be available in your area next year.

Despite funding for Medicare Advantage plans increasing by 4.3%, many insurers are facing financial pressures that will likely result in:

• Reduced benefits on existing plans
• Higher out-of-pocket costs
• Elimination of certain supplemental benefits
• Changes to provider networks

What This Means for Your Coverage

If your Medicare Advantage plan is discontinued in your area, you'll have the opportunity to select a new plan during the open enrollment period. You'll want to carefully review available options to ensure your preferred doctors and hospitals remain in-network and your prescription medications stay covered.

Healthcare Access Improvements Through Technology

AI-Powered Prior Authorization System

Medicare is implementing an innovative AI-powered system to speed up prior authorization approvals for important medical treatments. This pilot program initially launches in six states: Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington.

The system currently covers 17 medical needs, including:

• Pain management treatments
• Urinary incontinence support
• Various specialized therapies and procedures

If you live in one of these pilot states, you should experience faster approval times for treatments that previously required lengthy prior authorization processes.

Your Action Plan for Medicare Open Enrollment

Critical Dates to Remember

Medicare's open enrollment period runs from October 7 through December 15 each year. During this window, you can:

• Switch from Original Medicare to Medicare Advantage
• Change Medicare Advantage plans
• Add or drop Medicare Part D prescription drug coverage
• Return to Original Medicare from Medicare Advantage

Essential Steps You Should Take

1. Review Your Annual Notice of Change: Your current insurer must send this document by September 30, outlining any changes to your 2026 coverage.
2. Check Your Prescription Drug Formulary: Verify that your medications remain covered under your current plan and review any cost changes.
3. Compare Total Annual Costs: Don't just look at monthly premiums: calculate your total expected costs including deductibles, copays, and coinsurance.
4. Verify Provider Networks: Confirm your preferred doctors and hospitals will still be in-network if you're considering Medicare Advantage plans.
5. Evaluate Your Healthcare Needs: Consider any changes in your health status that might make different coverage options more beneficial.

How These Changes Impact Different Medicare Beneficiaries

High Prescription Drug Users

If you regularly take expensive medications, the $2,100 out-of-pocket cap continues to provide significant protection, even with the $100 increase. The Medicare-negotiated drug prices could substantially reduce your costs if you take any of the 10 affected medications.

Medicare Advantage Members

You'll need to pay close attention during open enrollment, as plan changes could significantly impact your coverage and costs. Some plans may reduce benefits or increase expenses to maintain profitability.

Original Medicare Plus Supplement Users

You'll primarily be affected by the Part B premium increases and Part D changes. The enhanced vaccine coverage provides additional value for your existing coverage.

Preparing for a Smooth Transition

The key to successfully navigating these Medicare changes lies in proactive planning and professional guidance. You don't have to figure this out alone: having expert support makes all the difference in securing the right coverage for your needs and budget.

At Borde & Associates, we specialize in helping families understand and navigate Medicare changes. Our team stays current with all Medicare updates and can help you evaluate how these 2026 changes specifically impact your situation.

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Whether you need help understanding how the prescription drug changes affect your specific medications, want to compare Medicare Advantage options, or need guidance choosing between Original Medicare and Medicare Advantage, we're here to provide the personalized support you deserve. Contact us today to schedule your complimentary Medicare review and ensure you're prepared for the changes ahead.