Use this month to review the mixed bag of changes to Medicare coming in 2026 and update your elections by December 7.
This year, Medicare turns 60, and a record 4.18 million Americans turn 65. Almost all Americans over 65 use Medicare, and the majority rely on it as their primary insurance. With some significant changes to Medicare coverage coming this year, just about everybody in this age bracket will want to take some time to consider their coverage, starting this month.
Medicare’s Annual Enrollment Period runs from October 15 to December 7 each year. If you’re already enrolled in Medicare, you can make changes to your plan now. It’s always good to consider your options during this period, since Medicare plans have changed, and your own health needs may have changed, as well. If you make any changes during this Open Enrollment Period, they’ll go into effect January 1, 2026.
For unbiased help choosing the right Medicare plans for you, contact your Medicare broker or your state’s SHIP (State Health Insurance Assistance Program). Here are some recent developments to discuss with them.
Medicare Prescription Payment Plans Will Automatically Re-enroll
This year, there’s no need to re-enroll in the Medicare Prescription Payment Plan (MPPP): if you had this plan in 2025, it will automatically carry over to 2026 unless you make a change. The MPPP is a free plan available to anyone with drug coverage under Medicare, whether with Medicare Part D or an Advantage plan. Instead of paying in a lump sum at the pharmacy for medications, MPPP enrollees will receive a bill monthly, along with their premium bill. Spreading out the cost of medications over the calendar year helps individuals keep up with payments and avoid sticker shock at the pharmacy.
Medicare Advantage Plans May Make Cuts to Coverage
Enrollees whose benefits include Special Supplemental Benefits for the Chronically Ill (SSBCI) should be aware of new restrictions on these benefits. Examples of benefits that CMS has deemed non-health related and that will not be covered include: cannabis, life insurance, unhealthy food, and cosmetic procedures.
In addition, the Congressional Budget Office predicts an overall 4% cut in Medicare payments to hospitals between 2026 and 2034 due to the budget reconciliation bill (One Big Beautiful Bill Act) passed by Congress in May. Medicare Advantage plan providers and hospitals will start looking now for ways to cut costs and maximize savings.
Medicare Savings Program Ease of Enrollment Will Vary By State
The same bill pushed back to 2035 updates to the Medicare Savings Program (MSP), which would have streamlined enrollment in the program. As a result, an estimated 1.38 million low-income Americans (with incomes at or below 135% of the federal poverty level) will no longer be able to pay the gaps in prescription coverage that the MSP helped them afford. Researchers estimate 18,200 preventable deaths per year as a result of this rollback. Since MSP is administered by states, states can still act to reduce barriers to enrollment in the program.
CMS Will Use AI to Expand Pre-authorization Under Original Medicare
This year, six states–New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington–will adopt the Centers for Medicare and Medicaid Services’ (CMS) new Wasteful and Inappropriate Service Reduction (WISeR) Model. For now, this pilot program will focus on evaluating eligibility for coverage of specific procedures like knee surgery, outpatient spinal injections, and certain categories of prosthetics and other medical equipment. Patients with Traditional Medicare in the six states who request these kinds of care will have their requests reviewed first by private AI companies and then by a clinician, according to CMS. While CMS says they intend the WISeR Model to eventually reduce Medicare waste, fraud, and abuse across the country, other experts worry that “the combined influence of automated screening and financial incentives may lead to clinically unjustified denials of care.” This is a shift, as WISeR will be applied under Original Medicare, while prior authorization has historically been required only under Medicare Advantage plans.
The takeaway for enrollees in 2026? If you live in one of the six states, be aware of which procedures are now subject to the WISeR Method, as their approval rates will be less predictable this year. And in 2027, keep an eye on the expansion of this model to other states and more kinds of care.
There’s also good news regarding prior authorization: new CMS regulations prohibit Medicare Advantage insurers from withdrawing prior authorization for care except in cases of obvious waste or fraud. According to Christine M. Clements, JD, a managed care law specialist, in Medscape News, “plans cannot use additional clinical information that might be available after they make their decision to reopen a coverage decision” unless the new information points to an obvious error in the original diagnosis. This is good news for both patients and providers.
If you consider all the changes and decide that your current plan will work just fine for 2026, you don’t need to take any action during this year’s Annual Enrollment Period. Your existing plan will continue on January 1.
Additional sources:
https://www.morganlewis.com/pubs/2025/07/cms-is-getting-wiser-about-medicare-waste-but-at-what-cost-to-providers
