In 2026, you’ll find Medicare Advantage has changed dramatically with the federal out-of-pocket maximum dropping to $9,250 and ten high-cost drugs now priced at least 38% lower through Medicare’s new negotiation program. Your prescription costs are capped at $2,100 annually, while new behavioral health parity rules guarantee equal treatment for mental health services. However, you’re facing fewer plan options as 9% of plans disappeared and major insurers exited hundreds of counties. The details below explain how these shifts affect your coverage choices and wallet.
Main Points
- Federal out-of-pocket maximum decreased to $9,250, but median plan limits rose 9.3% to $5,900 in 2026.
- Medicare negotiated prices for ten high-cost drugs, achieving at least 38% savings and a $2,100 annual prescription cap.
- New behavioral health parity rules require equal treatment for mental health and medical benefits starting January 2026.
- Available Medicare Advantage plans dropped 9%, with nearly 3 million enrollees losing coverage due to plan terminations.
- Major insurers exited markets, including UnitedHealthcare leaving 225 counties and affecting over 600,000 members.
Lower Out-of-Pocket Maximums for 2026
While the federal out-of-pocket maximum for Medicare Advantage plans has decreased to $9,250 for 2026—down $100 from 2025’s limit—this marks the first reduction after years of consecutive increases.
However, you shouldn’t expect lower cost options across the board. The national median maximum out-of-pocket has risen from $5,400 in 2025 to $5,900 in 2026—a 9.3% increase in just one year.
Additionally, 11% fewer plans offer out-of-pocket limits below the CMS threshold, meaning you’ll find fewer lower-cost protection options when selecting your coverage.
Once you reach your plan’s out-of-pocket maximum, your Medicare Advantage plan covers 100% of approved in-network services for Parts A and B for the remainder of the year, though these affordability challenges may still impact your healthcare decisions. Keep in mind that out-of-pocket costs will vary depending on your individual Medicare Advantage plan and personal circumstances.
What the New Behavioral Health Parity Rules Mean
The Mental Health Parity and Addiction Equity Act (MHPAEA) final rules, released on September 9, 2024, represent a significant shift in how your health plan must cover mental health and substance use disorder services.
New federal rules mandate equal treatment standards for mental health and medical benefits starting 2026.
Starting January 1, 2026, your plan must provide meaningful behavioral health benefits that match medical and surgical coverage standards. This means insurers can’t impose stricter prior authorizations, higher claim denial rates, or more restrictive networks for mental health care.
Your plan must now analyze outcome data comparing behavioral health access to medical care, including network composition and denial percentages. If disparities exist, changes are required.
For Medicare Advantage beneficiaries, proposed rules would limit in-network behavioral health cost sharing to Traditional Medicare levels, potentially reducing your out-of-pocket expenses for mental health services. However, proposals related to behavioral health parity for better access in MA plans were deferred due to strong stakeholder interest and will require future rulemaking.
How Prescription Drug Costs Are Dropping
You’ll notice significant relief at the pharmacy counter this year as Medicare’s drug price negotiation program takes effect.
The first 10 negotiated medications now cost at least 38% less than their 2023 list prices, saving you and other Medicare beneficiaries an estimated $1.5 billion annually in out-of-pocket costs.
Beyond these negotiated prices, you’re also protected by a new $2,100 annual cap on your prescription drug expenses, ensuring you won’t face catastrophic costs even if you require multiple medications.
These negotiated prices will be updated annually based on inflation adjustments, maintaining their value as long as the drugs remain in the program.
Negotiated Drug Pricing
Starting January 1, 2026, Medicare’s negotiated prices for ten high-cost prescription drugs will deliver substantial savings to millions of beneficiaries.
These negotiation strategies target single-source brand medications without generic or biosimilar competition, focusing on treatments where Medicare spends the most.
The drug selection process has identified medications treating:
- Diabetes (Januvia, dropping from $527 to $113)
- Heart failure (Entresto)
- Cancer
- Blood clots and psoriasis
You’ll save an estimated $1.5 billion collectively in out-of-pocket costs annually, while Medicare saves $6 billion on these ten drugs.
The negotiated prices average at least 50% off list prices, with minimum discounts of 38%. Your Medicare Advantage or Part D plan must include these medications in their formularies, ensuring you’ll access these lower prices. Looking ahead, Medicare will negotiate prices for an additional 15 drugs in 2025, with those reduced rates taking effect in 2027.
Insulin and Vaccine Savings
Beyond these negotiated medications, your insulin costs have dropped considerably under Medicare’s $35 monthly cap. This affordable rate applies to one-month supplies across Medicare Part B and Part D, with no deductible required.
Improved insulin accessibility means you’ll pay predictable amounts rather than facing unexpected spikes in medication costs. For the 8.4 million Americans managing diabetes with insulin, this change delivers meaningful financial relief. To maximize your insulin coverage, enrollment in both Part B and Part D is necessary for comprehensive access to all insulin types and administration methods.
Vaccine affordability has also improved greatly. You’ll now receive all recommended vaccines at no cost through Medicare Part D plans in 2026.
The Inflation Reduction Act eliminated copayments and coinsurance for preventive vaccines, ensuring you can protect yourself against preventable diseases without financial barriers. This coverage extends to Medicare Advantage plans offering prescription drug benefits, supporting thorough preventive care.
Which 10 Drugs Have Newly Negotiated Prices
The Inflation Reduction Act‘s first drug price negotiation cycle targets ten brand-name medications that account for massive Medicare Part D spending.
These negotiated prices take effect January 1, 2026, delivering substantial savings while maintaining drug effectiveness for treatments you rely on.
The selected medications include:
Ten high-cost medications covering diabetes, heart disease, and blood clotting treatments now feature negotiated Medicare prices starting in 2026.
- Januvia – diabetes treatment dropping from $527 to $113 for a 30-day supply
- Entresto – heart failure medication with significant price reduction
- Eliquis – blood thinner used by hundreds of thousands of beneficiaries
- Jardiance – diabetes and heart failure drug with negotiated pricing
You’ll see minimum 38% discounts across all ten drugs, with most achieving at least 50% off their 2023 list prices.
These reductions apply whether you’re paying out-of-pocket or through your plan’s coverage phases. The negotiated prices will remain in effect as long as drugs remain in the negotiation program.
Fewer Medicare Advantage Plans Available This Year
Medicare Advantage plan options are shrinking considerably in 2026, with nearly 3 million enrollees losing their current coverage through plan terminations and service area reductions.
Plan availability has dropped from 3,719 to 3,373 individual MA plans nationally—a 9% decrease. You’ll find fewer choices too, with the average beneficiary now selecting from 32 MA-PD plans instead of 34.
These market changes hit hardest in specific areas. New Hampshire lost 13 plans while Minnesota lost 11, with UCare nearly exiting the state entirely.
Local PPOs experienced the largest disruption, affecting 1.5 million enrollees. If you’re in a rural county, you’re particularly vulnerable as UnitedHealthcare and Humana reduced their rural offerings.
Despite this contraction, MA enrollment should stabilize around 34 million since most affected enrollees will switch plans rather than leave Medicare Advantage entirely. Special needs plans including D-SNP, C-SNP, and I-SNP have remained stable throughout these market fluctuations.
Supplemental Benefits Being Cut in 2026
You’ll notice significant changes to your supplemental benefits this year, with many plans reducing or eliminating coverage for transportation, meals, and over-the-counter items.
While core benefits like dental and vision remain relatively stable, the allowances and percentages for these services have decreased across most plans.
These cuts stem from regulatory pressures and rising out-of-pocket limits, forcing insurers to reallocate resources toward benefits that demonstrate measurable health outcomes. The availability of Special Supplemental Benefits for chronically ill beneficiaries has also decreased, limiting access to targeted health supports for those with ongoing medical needs.
Declining Allowance Percentages Explained
As insurers grapple with compressed margins from regulatory changes, they’re slashing supplemental benefit allowances across the board for 2026.
You’ll see significant reductions in dental coverage value as major carriers like UnitedHealthcare and Elevance Health restore profitability. The average member is experiencing cuts of $6 per month in supplemental benefits.
Here’s what’s changing:
- Over-the-counter allowances are declining as plans reprioritize resources
- OTC card benefits now require chronic condition qualifications for food and utilities
- Fitness memberships and prepaid flex cards are being eliminated or reduced
- Dental, previously a key enrollment driver, faces material value reductions
While core benefits like hearing and vision remain relatively stable, you’re witnessing a strategic recalibration that prioritizes measurable health outcomes over generous allowances. CMS now requires supplemental benefits to have “clinical value,” fundamentally reshaping which perks insurers can offer.
Transportation and Meal Reductions
While dental and over-the-counter allowances grab headlines, transportation and meal benefits are experiencing some of the sharpest cuts in 2026.
You’ll find tighter transportation limits, with rides restricted to medical appointments only and longer scheduling lead times. Many plans cap coverage at 10 one-way rides annually—that’s just 5 round trips.
Meal eligibility has tightened considerably. The share of general enrollment plans offering meals dropped from 65% to 57%, while many insurers slashed meal quantities from 28 to 14 per benefit period.
You’ll now need specific diagnoses like congestive heart failure to qualify for certain meal benefits under Special Supplemental Benefits for Chronically Ill (SSBCI) restrictions.
Review your Annual Notice of Change this fall to verify these benefits haven’t disappeared from your plan. During Open Enrollment periods, compare alternative plan options if your current coverage no longer meets your transportation and meal needs.
Vision and Dental Coverage
Though vision and dental benefits remain nearly universal across Medicare Advantage plans—with 99% and 98% offering these perks respectively in 2026—the quality and scope of this coverage is quietly eroding.
When conducting a vision benefits comparison, you’ll notice routine exams shifting from annual to biennial frequency, eyewear allowances decreasing, and network restrictions tightening.
Your previously flexible $300 frame allowance might drop considerably or require specific retailers.
Dental service limitations are even more concerning:
- Annual maximums capped at $1,000–$2,000 won’t cover major procedures
- Waiting periods now delay access to crowns and root canals
- Coverage increasingly excludes major services like implants
- Network requirements eliminate out-of-network flexibility
UnitedHealthcare’s addition of coinsurance to extensive dental plans exemplifies this trend, forcing you to shoulder more costs despite maintaining premium payments.
Remember that while these supplemental benefits may change, plans must still cover all medically necessary Part A and Part B services as required by Medicare regulations.
How Medicare Advantage Part B Premium Reductions Work
Medicare Advantage Part B premium reductions allow you to recoup some or all of your standard Part B premium, which stands at $202.90 monthly in 2026.
These premium reduction mechanisms work through rebate portions of CMS payments that plans receive, applying uniformly to all enrollees.
In 2026, 32% of individual Medicare Advantage plans offer this giveback benefit, with 36% providing more than $100 monthly.
The beneficiary eligibility criteria are straightforward—if you’re enrolled in a plan offering this reduction, you’ll automatically receive it regardless of income.
This benefit operates separately from your Medicare Advantage plan premium, which 67% of plans charge at $0. Plans use rebate dollars to cover the costs of these premium reductions or to fund extra benefits like vision and dental coverage.
Reductions range from 10 cents to the full $202.90 premium, helping offset your Medicare costs.
Automatic Enrollment in the Prescription Payment Plan
Starting in 2026, your enrollment in the Medicare Prescription Payment Plan will automatically renew each year if you participated the previous year and haven’t changed your drug coverage.
This automatic enrollment benefits you by eliminating annual re-enrollment hassle while maintaining your interest-free monthly payment option for prescription costs.
The participation confirmation process works seamlessly:
- You’ll receive a confirmation letter in December if your plan remains unchanged
- Your pharmacy gets notified automatically—no upfront payment required
- You must actively opt out if you don’t want to continue
- Maximum out-of-pocket costs cap at $2,100 for 2026
If you didn’t participate in 2025 but want to join for 2026, you can opt-in as early as October 15, 2025.
What Provider Notification Changes Mean for You
When you’re choosing a Medicare Advantage plan, knowing whether your preferred doctors and specialists participate in network is essential—and 2026 brings significant improvements to help you make informed decisions.
You’ll now access provider directories directly on Medicare Plan Finder without maneuvering to external sites, making comparisons easier. Plans must submit directory information to CMS by January 1, 2026, with updates reported within 30 days of changes. MA plans remain accountable for directory accuracy, even when they’ve delegated the management to other entities.
If you discover your preferred provider isn’t in-network within three months of enrollment (for elections made January 1 through December 1, 2026), you’ll qualify for a temporary Special Enrollment Period.
Additionally, when providers submit coverage requests on your behalf, they’ll receive provider notifications alongside your notice, ensuring everyone stays informed about enrollment implications and coverage decisions affecting your care.
Which Insurers Are Leaving Medicare Advantage Markets?
You’ll notice major changes across Medicare Advantage markets in 2026, with UnitedHealthcare exiting 225 counties and affecting over 600,000 members nationwide.
If you’re among those losing coverage, you’ll need to act quickly during your Special Enrollment Period to select a new plan before January 1st.
Your options include switching to another Medicare Advantage plan in your area, enrolling in Original Medicare with or without a supplement, or selecting a standalone Part D prescription drug plan.
Additionally, Michigan Medicine is exiting the MA market entirely, impacting over 9,000 Medicare Advantage members who will need to find alternative coverage.
UnitedHealthcare’s Market Exits
The Medicare Advantage landscape is experiencing its most significant upheaval in years, with major insurers retreating from hundreds of counties across the United States.
UnitedHealthcare’s market exits represent one of the most dramatic shifts, with the insurer withdrawing from 225 counties in 2026. You’ll see UnitedHealthcare strategies focusing on profitability over geographic reach, as county coverage drops from nearly 90% to roughly 80% nationwide.
The Medicare Advantage impacts you’ll experience include:
- Coverage reductions across 16 states, primarily affecting rural communities
- Net loss of 211 counties despite entering 14 new markets
- Complete withdrawal from Vermont alongside other carriers
- Provider network disruptions with Mayo Clinic and Providence Clinical Network
Bobby Hunter, CEO of Government Programs at UnitedHealthcare, cites CMS funding cuts, rising healthcare costs, and increased utilization as unavoidable headwinds driving these decisions.
Humana is following a similar trajectory, exiting 198 counties while struggling to maintain its previous market position alongside UnitedHealthcare’s broader retreat.
Impact on Current Enrollees
Beyond UnitedHealthcare’s widespread county exits, you’re facing a broader crisis as dozens of insurers completely abandon the Medicare Advantage market or pull out of entire regions.
Eighteen marketing organizations announced full departures, while hundreds of thousands of enrollees must find new coverage.
If you’re among UCare’s 158,000 Minnesota and Wisconsin members, Premera’s 30,000 Washington enrollees, or Vermont Blue Advantage’s 26,034 members (representing 71% of Vermont’s MA market), you’ll need to shift by year-end.
Member shifts are complicated by coverage gaps created when regional carriers like Samaritan Health Plans and Sentara Medicare exit specific service areas.
Michigan Medicine, Ochsner Health Plan, and Blue Cross Blue Shield Vermont are completely discontinuing their MA offerings, forcing thousands to shop for replacement plans amid shrinking options.
Major insurers like UnitedHealth, Aetna, and Humana are withdrawing from some markets, contributing to the consolidation affecting up to 1.8 million seniors.
Finding Alternative Plan Options
Eighteen major insurers have abandoned Medicare Advantage entirely or pulled out of entire states, leaving you with dramatically fewer choices for 2026 coverage.
With 3,373 non-SNP plans remaining nationwide—down 10% from last year—you’ll need to act quickly when comparing plans.
Major carriers still offering coverage include:
- UnitedHealthcare (covering 94% of Medicare-eligible individuals)
- Humana (available in 85% of U.S. counties)
- Aetna (with reduced service areas)
- CVS Health (offering limited Medicare Advantage options)
Understanding benefits becomes critical as your options shrink.
Counties that previously had multiple carriers now face consolidated offerings, making thorough plan comparison essential. PPO plans have been particularly affected by the market shakeup, experiencing a 12% decline in offerings compared to an 8% decrease for HMO plans.
You’ll need to evaluate premiums, prescription coverage, provider networks, and out-of-pocket maximums to find suitable replacement coverage before enrollment deadlines.
Frequently Asked Questions
Can I Switch From Original Medicare to Medicare Advantage in 2026?
Yes, you can switch from Original Medicare to Medicare Advantage in 2026 during the Annual Enrollment Period from October 15 to December 7, with coverage starting January 1.
You’ll need to meet Medicare eligibility changes requirements, including having both Part A and B, living in your plan’s service area, and being a U.S. citizen or lawfully present.
The switching process is straightforward during this enrollment window.
What Happens if My Current Medicare Advantage Plan Is Discontinued?
Worried about losing your health coverage?
If your Medicare Advantage plan‘s discontinued, you’ll automatically shift to Original Medicare on January 1, 2026.
You’ll receive notice by early October, giving you time to explore plan options during the Annual Enrollment Period through December 7.
You can also use the Special Election Period until February 28 to enroll in another Medicare Advantage plan, avoiding coverage changes that could affect your prescriptions and benefits.
Are Telehealth Benefits Still Covered Under Medicare Advantage in 2026?
Yes, your Medicare Advantage plan continues covering telehealth benefits through 2026.
Unlike Original Medicare’s returning restrictions, MA plans maintain telehealth expansions including in-home services without geographic limitations.
You’ll have virtual visit accessibility for both medical and mental health care through audio-only and audio-video options.
However, coverage details vary by carrier, so you should verify your specific plan’s telehealth benefits and cost-sharing requirements directly with your insurer.
How Do I Qualify for a Special Needs Plan?
You’ll qualify for a Special Needs Plan by meeting specific eligibility criteria beyond basic Medicare requirements.
Coincidentally, just as you’re researching this, CMS has updated 2026 requirements.
You must have Medicare Parts A and B, plus fall into one category: living in an institution (I-SNP), having both Medicare and Medicaid (D-SNP), or managing qualifying chronic conditions like diabetes or heart failure (C-SNP).
Your doctor must document your condition.
Can I Keep My Doctors if I Switch Plans?
Keeping your doctors depends on your new plan’s doctor network. Before switching, check if your preferred providers are in-network using Medicare Plan Finder.
Traditional Medicare offers the most plan flexibility, letting you see any participating physician. Medicare Advantage plans have varying network sizes—some include only 32% of available doctors while others cover 63% or more.
If you discover your doctor isn’t covered after switching in 2026, you may qualify for a special enrollment period to change plans again.
Final Thoughts
You’re entering a transformative year for Medicare Advantage, with over 10 million enrollees expected to benefit from the $2,000 prescription drug cap alone. While you’ll face fewer plan options—down 17% from last year—you’re gaining stronger protections and lower costs where it matters most. Don’t let these changes catch you off guard. Review your coverage now, compare your options carefully, and make sure you’re maximizing every new benefit available to you in 2026.