D. Kenton Henry
Editor, agent, broker
30 SEPTEMBER 2025
Medicare 2026: Welcome clients and prospective clients! Before reading this (if you have not already), you should go to your mail box and retrieve your 2026 Annual Notice of Change from Medicare. You were due to receive it no later than today per Center For Medicare Rules and Regulations. If will give you a good idea if you need to re-shop your Medicare Advantage or Part D Drug plan for the coming calendar year. If not, the following changes may.
10 changes to review before the Annual Election period, often referred to as the Open Enrollment (Oct 15–Dec 7)
If you’re on Medicare, 2026 brings important updates—especially to prescription drug coverage. The Part D out-of-pocket cap rises to $2,100, the standard deductible becomes $615, and Medicare’s first negotiated drug prices start on January 1, 2026. Medicare Advantage also gets new guardrails around prior authorization and appeals, and some supplemental “perks” are being narrowed. Check your Annual Notice of Change (ANOC) (it should arrive by Sept 30) and compare your plan options—small differences can mean big savings. If you’d like help, I’ll review your medications, doctors, and benefits to make sure you’re in the right fit for January 1.
Here is an itemized list of the 10 Key Changes:
Medicare changes your 2026 plan review should cover
1) Part D’s annual out-of-pocket cap rises to $2,100.
Once a member’s 2026 Part D out-of-pocket spending reaches $2,100, they’ll pay $0 for covered Part D drugs for the rest of the calendar year.
2) The standard Part D deductible increases to $615.
Plans can’t set a deductible higher than $615 in 2026 under the redesigned Part D rules.
3) Drug price negotiations start showing up at the counter.
Medicare’s first set of negotiated Maximum Fair Prices (MFPs) for 10 widely used Part D drugs take effect January 1, 2026. Members should review their ANOC and plan formularies to determine how these prices impact their medications.
4) Insulin and adult vaccines: protections continue.
Part D insulin remains capped and no-deductible; starting in 2026, the cap is the lesser of $35, 25% of the MFP, or 25% of the negotiated price. ACIP-recommended adult vaccines remain $0 under Part D.
5) “Pay-over-time” for prescriptions auto-renews.
The Medicare Prescription Payment Plan (monthly billing instead of paying large amounts at the pharmacy) auto-renews in 2026 unless the member opts out. It smooths payments but doesn’t lower total costs—good to remind clients who tried it in 2025.
6) Medicare Advantage prior-auth and appeals guardrails tighten.
For 2026, CMS says MA plans must honor previously approved inpatient admissions (can only reopen for obvious error or fraud), and CMS closes appeals loopholes so members and providers receive required notices and can appeal adverse coverage decisions. Expect fewer mid-stay reversals. Centers for Medicare & Medicaid Services
7) Limits on certain “extra perks” in MA (SSBCI) take effect.
CMS codified non-allowable Special Supplemental Benefits for the Chronically Ill—examples include non-healthy food, alcohol, tobacco, and life insurance. Some plans may rebalance extras as a result.
8) Star Ratings update: new/returning measures.
2026 Stars add or reintroduce measures like Kidney Health Evaluation for Patients with Diabetes plus Improving/Maintaining Physical and Mental Health (weight = 1). Tougher cut points in 2026 may shift plan bonuses and benefit richness—worth watching locally.
9) Part D benefit design shifts behind the scenes.
Liability shares change across phases (plans, manufacturers, CMS), and there’s a new subsidy for selected (negotiated) drugs. Members may see formulary/tier adjustments—another reason to compare plans.
10) ANOC timing: what to tell clients.
Remind everyone: Annual Notice of Change (ANOC) letters arrive by September 30 each year; if they didn’t see one, call the plan. Open Enrollment runs Oct 15 – Dec 7 for Jan 1 effective dates.
- Check your Annual Notice of Change (ANOC) (it should arrive by Sept 30) and compare your plan options—small differences can mean big savings. If you’d like help, I’ll review your medications, doctors, and benefits to make sure you’re in the right fit for January 1.
Other Developments
- Some Medicare Advantage supplemental benefits (i.e. nutrition support, OTC medicine) may be reduced in favor of core services.
- In six states, prior authorizations for certain Original Medicare services will be tested.
- Part B and Part D premiums and deductibles are both set to increase—Part B premium up ~11.6%, and Part D premium by about 6%.
Who Am I?
In addition to being the editor of this blog I have has been helping individuals and families navigate the health and Medicare insurance landscape since 1986. With nearly four decades of experience, he specializes in Medicare Supplement, Medicare Advantage, and Medicare Part D prescription drug plans.
As an independent broker, I am appointed with virtually every competitive, A-rated Medicare insurance company in Texas, Indiana, Ohio, and Michigan. This broad access allows him to recommend the plan that truly best fits each client’s needs.
Above all, I work for my clients—not the insurance companies. You will never pay more by enrolling through me than you would if you purchased an insurance product directly from the carrier. My mission is to provide clear guidance, personalized recommendations, and ongoing support to ensure my clients get the coverage and peace of mind they deserve.
If you have any questions about 2026 Medicare Part D prescription drug plans, Medicare Advantage, or Medicare Supplement (Medi-Gap) policies, please give me a call.
D. Kenton Henry
Office: 281-367-6565
Text my cell 24/7 @ 713-907-7984
Email: Allplanhealthinsurance.com@gmail.com
For all the latest news on health and Medicare related insurance, please follow me on my blog @ Https://HealthandMedicareInsurance.com
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FEATURE ARTICLE 1
By: Elizabeth Casolo Friday, September 26th, 2025
Average premiums, benefits and plan choices for Medicare Advantage and the Medicare Part D prescription drug program should remain relatively stable next year, CMS said in a Sept. 26 news release. But MA enrollment is projected to decrease 900,000 in 2026.
Despite a slight dip in available MA plans nationally, over 99% of Medicare beneficiaries will still be able to access an MA plan.
The agency estimates the premiums for MA plans to drop from $16.40 to $14.00. On average, the total premium for standalone Part D is estimated to fall $3.81.
CMS’ July forecast predicted elevated Medicare Part D base premium increases in the neighborhood of 6%.
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