As we approach the annual enrollment period starting in October, you may be wondering about Medicare changes coming in 2026 and beyond. While there are many unknowns, we do know some changes through the Final Rule and some insurance market changes. In this article, we’ll review Medicare news in the leadership of Centers of Medicare and Medicaid Services (CMS) and the Department of Health and Human Services (HHS), the release of the Final Rule for Medicare in 2026, and some other recent Medicare news updates.
Recently, the U.S. Congress has confirmed the nominations of the new Secretary of HHS, Robert F. Kennedy Jr., and the new CMS Administrator Dr. Mehmet Oz. The administrator’s new policy is still evolving. As part of a goal to reduce government spending, HHS has eliminated around 10,000 jobs and has cut several million dollars of grants for medical research. While the administration aims to reduce spending, these cuts to medical research could present challenges to achieving long-term goals in chronic disease reduction, an area Dr. Oz highlighted as a priority.
Dr. Oz outlined several goals for CMS including focusing on overall health and reducing chronic disease, reducing fraud, waste, and abuse, and improving transparency for Medicare beneficiaries about Medicare costs. And to that end there have been some changes to Medicare policy already as detailed below.
The CMS “final rules” are final regulations that CMS will implement in the next year, after a period of review and public comment. The previous administration proposed the final rule in the early days of January, and now, CMS has finalized the rule for Medicare for 2026 with some key changes.
First, the rule clarifies the policy for private Medicare Advantage, Part D, or Medicare Supplement insurance carriers to deny claims. Importantly, under this rule, insurance companies generally can’t deny payment for a medical service after you’ve already received it.
For example, if your doctor is approved by Medicare to provide a treatment, the insurer can’t say it was medically unnecessary after the treatment based on new information, unless there is an obvious error or fraud. This proposed change means that if your Medicare Advantage plan pre-approves a hospital stay, they could not change their mind and deny coverage later unless they find a clear mistake or fraud on the initial request. This could offer you greater peace of mind and protection from unexpected medical bills after a service was approved.
Secondly, the rule also aims to close loopholes for appealing Medicare claim denials by making official guidance that enrollees must be given advanced notice of their claim being denied, giving them more time to appeal the decision and not delaying or negatively impacting their care.
An earlier proposal for Medicare to pay for GLP-1 drugs (Wegovy, Trulicity, Ozempic, etc.) for obesity was not included in the final rule. Now, Medicare does cover these prescriptions for the treatment of conditions like diabetes and heart disease, but the previous administration did propose allowing Medicare to cover these drugs for obesity as well, a condition that affects a large percentage of the Medicare beneficiary population. Beneficiaries concerned about obesity and its related health conditions may want to discuss all available treatment options and their coverage implications with their healthcare providers. Preventing complications from chronic diseases is also a key component of long-term health and well-being.
The new administration has directed CMS to continue the Medicare Drug Price Negotiation Program — working with pharmaceutical companies to negotiate common and necessary prescription drug prices to be more affordable for Medicare beneficiaries, an initiative started under the Inflation Reduction Act.
The first list of 10 drugs was released late last year to take effect in 2026, and included discounts up to 79% for prescriptions for diabetes, heart disease, psoriasis, and other conditions. CMS has been directed to save beneficiaries even more money on prescriptions starting in 2028. While we don’t know what’s on the list for 2028 yet, it’s good news for beneficiaries who rely on monthly supplies of their medications that the program will continue.
Last year’s Annual Enrollment Period was volatile with insurance companies increasing premiums, removing Medicare Advantage or Medicare Part D plans from their offerings, or leaving regions or whole states altogether. And it’s looking like AEP 2026 may be similar. Already in spring 2025, Elevance (formerly Anthem) has decided to stop marketing many of their Medicare Advantage plans. While they are still available, beneficiaries may not see them listed on websites and brokers may have to renew existing plans for their customers manually. Insurers have to weigh the cost of promoting these plans in certain markets against the profitability of these plans.
Even though Medicare Advantage enrollment is expected to grow, insurance carriers are promoting their special needs plans for eligible beneficiaries which tend to be more predictably reimbursed by the government. Special needs plans (SNPs) have additional benefits and specialized care for beneficiaries with chronic conditions (C-SNPs) or who are dually eligible for Medicaid (D-SNPs). These market shifts may mean that the types of plans beneficiaries available in AEP may change, so it’s important for beneficiaries to review the coverage they need and any changes coming to their plan or benefits.
As of this writing, Congress is working on the budget and has been directed to find $880 billion to cut from the federal budget. The House Energy and Commerce committee released one of the first attempts at a budget reconciliation in early May. The proposed budget would cut spending by more than the proposed $880 billion through 2034, but a good portion would be coming from Medicaid and impacting health coverage for millions, especially those beneficiaries who received Medicaid through meeting a low-income threshold.
Losing Medicaid would mean losing assistance with Medicare out-of-pocket costs or affecting coverage for long-term care services, which Medicare largely does not cover. However, this is just one proposal that needs to be voted on by the House, the Senate, and signed by the president. If you are a Medicaid beneficiary, stay vigilant on any changes to funding to your state’s Medicaid program. You can also reach out to your State Health Insurance Assistance Programs (SHIPs) or local Area Agencies on Aging for information and assistance. These organizations can provide personalized guidance on navigating changes and accessing available benefits.
News changes fast and a lot is unknown for Medicare. However, by staying up to date with your insurance carrier and legislation, you can be prepared for making your healthcare decisions for your coverage in 2026.
Disclaimer:
The information presented in this article is current as of its publication date. However, news, regulations, and policies, especially concerning programs like Medicare, can change frequently. While SmartMatch strives to provide timely and accurate information, we cannot guarantee that all details will remain up-to-date indefinitely. Readers are encouraged to consult official sources, such as Medicare.gov, or contact relevant agencies for the most current information before making any decisions based on the content of this article. This article is for informational purposes only and should not be considered financial or medical advice.
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