As we approach the new plan year, it’s important to know that Medicare Advantage plans…
What’s New in 2026
What’s new for beneficiaries:
- Improved protections on coverage decisions — Medicare Advantage (MA) and Part D plans must generally honor approved prior authorization decisions for the duration of the approved course of treatment, reducing the risk that beneficiaries lose coverage after approval.
- Stronger appeals rights — CMS clarified which plan decisions are appealable and strengthened notice requirements, helping beneficiaries understand and challenge coverage denials.
- More support for Dual Eligible Special Needs Plans (D-SNPs) — CMS strengthened consumer protections and care coordination requirements for plans serving people enrolled in both Medicare and Medicaid.
- Part D drug cost and data changes — Part D plans must integrate with the Medicare drug price negotiation data system and make required formulary adjustments, increasing transparency and, for some drugs, reducing beneficiary out-of-pocket costs.
These aren’t just technical tweaks — they change plan behavior and help protect beneficiaries from unexpected coverage denials or confusing practices.
Provider Directory Transparency Requirements
What’s changing
CMS finalized a rule requiring Medicare Advantage plans to:
- Submit provider directory data regularly to CMS, and
- Attest annually that the data are accurate.
Why it matters
This aims to reduce “ghost networks,” where providers are listed as in-network but are unavailable to beneficiaries.
Prior Authorization in Traditional Medicare (Pilot Program)
New for 2026
Traditionally, Original Medicare (fee-for-service) didn’t require broad prior authorization — but in 2026 CMS is launching a pilot prior authorization model in select states, leveraging technology to review certain outpatient services before payment.
Who it affects
- This applies to traditional Medicare only in participating states (e.g., Arizona, Ohio, Oklahoma, New Jersey, etc.).
- Medicare Advantage plans are not affected by this particular pilot.
Potential beneficiary impact
- Some procedures in those states may require approval before Medicare pays for them. This could slow access or add extra steps for patients and providers.
Part D Drug Coverage Redesign & Negotiations
- Continued Implementation of Big Changes
Under the Inflation Reduction Act, key rule adjustments continue into 2026:
- The annual out-of-pocket spending cap remains in effect, protecting beneficiaries from catastrophic prescription drug costs.
- Drug price negotiations continue to take effect, meaning negotiated price reductions on selected high-cost medications that may lower costs at the pharmacy.
These rules don’t change eligibility, but they change what beneficiaries pay and how plans must structure coverage.
Access & Coverage Protections
New enrollment protections
2026 changes include:
- Special enrollment periods (SEPs) for people who chose a Medicare Advantage plan based on inaccurate provider directory info — giving them a chance to switch plans outside regular windows.
Better consumer protections
CMS and advocacy groups are pushing for:
- Stronger oversight and enforcement to limit the use of inappropriate internal coverage criteria, preventing MA plans from denying services based on overly broad or non-transparent internal rules.
These rulemaking efforts aim to standardize how benefits are applied and protect beneficiaries from unpredictable plan behavior.
What proposed future rules could mean
CMS has also proposed additional changes for 2027 that are not yet final but could significantly affect beneficiaries if adopted:
- Additional safeguards around MA plan use of artificial intelligence decisions
- Expanded reporting requirements on prior authorization and network adequacy
- Enhanced oversight of MA agent and broker marketing practices
- Broader formulary standards for lower-cost drugs
Because these are proposals rather than final rules, they’re still under review and may change before implementation.
What This Means for You
Overall Rule Impact on People with Medicare
✔️ More transparency and better protections in Medicare Advantage plan coverage decisions
✔️ Increased accuracy in provider directories to help select the right plan
✔️ New pilot prior authorization program for some traditional Medicare services
✔️ Ongoing changes to drug pricing and cost-sharing that can lower out-of-pocket costs
✔️ Better appeals rights and clarity around plan decisions
Bottom Line: Medicare isn’t just raising costs — regulatory changes in 2026 alter how coverage works in practice, especially in Medicare Advantage and prescription drug benefits, and aim to strengthen protections for beneficiaries.
