Changes to Medicare Advantage in 2026: Key Official Updates

As Changes to Medicare Advantage in 2026 These include important updates to coverage rules, recourse rights, supplemental benefits, star ratings, plans for people with Medicare and Medicaid Part D, and payments to plans. These changes were primarily defined by Centers for Medicare & Medicaid Services, known as CMS, the federal agency responsible for administering Medicare.

However, it's important to understand one point from the outset: the federal changes do not make all plans the same. Each Medicare Advantage plan may still have different characteristics. Network, costs, extra benefits, medication coverage, authorization rules, and service area are specific to each area..

Furthermore, not every proposal released by the CMS became final rule. Therefore, when analyzing the Changes to Medicare Advantage in 2026The beneficiary must separate what has been officially finalized from what remains only a proposal.

In this guide, you will understand the main official updates for 2026, how they may affect beneficiaries, and where to confirm information from reliable sources, such as... Medicare.gov, Medicare Plan Finder, CMS.gov and official Medicare care channels.

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Overview of changes to Medicare Advantage in 2026

Medicare Advantage, also called Medicare Part CThese plans are offered by private companies approved by Medicare. They must cover almost all medically necessary services covered by the original Medicare plan, although they operate under their own rules regarding network coverage, costs, and access.

Many Medicare Advantage plans also include Part D drug coverage and additional benefits such as dental, vision, hearing, transportation, fitness programs, telehealth, and over-the-counter products.

For the contract year of 2026, the CMS published a final rule with changes related to:

• decisions regarding hospital coverage;
• right of appeal;
• communicating negative responses;
• financial responsibility of the beneficiary;
• supplemental benefits for people with chronic diseases;
• rules for special plans aimed at people with Medicare and Medicaid;
• Medicare Prescription Drug Payment Program;
• Insulin and vaccine coverage by Part D;
• star rating;
• payments and risk adjustment;
• protection and information for the beneficiary.

The final rule for the contract year 2026 was published by CMS on April 4, 2025. It updated policies for Medicare Advantage, Medicare Part D, Medicare Cost Plans, and PACE.

However, the CMS also made it clear that it had not finalized some proposals at that time. These included specific proposals regarding annual equity review in utilization management, limits on the use of artificial intelligence in Medicare Advantage, and Part D and Medicaid coverage for anti-obesity medications.

This is essential because a public proposal can generate headlines, but It should not be treated as a definitive rule.Before making a decision, the beneficiary should confirm what actually appears in the final rule, in the plan documents, and in the official tools.

What is Medicare Advantage?

Medicare Advantage is an alternative way to receive Medicare coverage. Instead of using Medicare Original directly for most services, the beneficiary receives coverage through a private plan approved by Medicare.

According to Medicare.gov, Medicare Advantage plans provide Part A and Part B benefits to people with Medicare. In many cases, they also offer Part D drug coverage.

In practice, these plans may include:

• network of doctors and hospitals;
• need for prior authorization;
• Referral to specialists;
• copayments;
• cost sharing;
• annual spending limit;
• extra benefits;
• Specific rules for medications;
• defined service area.

In addition, the person needs to remain on Medicare. Generally, to enroll in a Medicare Advantage plan, it is necessary to have Part A and Part Bto live within the plan's service area and be legally present in the United States.

Quick overview of the main changes for 2026

Area	What has changed or been reinforced?	What the beneficiary should observe
Hospitalizations approved	Plans have limits on reopening certain approvals that have already been granted.	Keep authorizations and communications from the plan.
Resources	Decisions made during consultations may give rise to rights to notification and appeal.	Read rejection letters and pay attention to deadlines.
Plans for Medicare and Medicaid	Integration and coordination rules advance for Medicare and Medicaid beneficiaries.	Check if the plan meets your type of Medicaid requirements.
Special benefits for chronic diseases	Special benefits receive clearer limits.	Confirm eligibility and permitted items.
Star rating	Weights and measures will change for 2026.	Don't choose a plan based solely on the stars.
Part D	Rules regarding insulin, vaccines, and installment payments remain relevant.	Confirm costs at the pharmacy and with your health plan.
Payments to plans	CMS projected an average increase in government payments to plans.	This does not guarantee an increase in individual benefits.
Official sources	Medicare.gov, Medicare Plan Finder, CMS, and SHIP remain the primary resources.	Avoid making decisions based solely on advertisements.

Plans must comply with certain hospitalization approvals.

One of the Changes to Medicare Advantage in 2026 The most important aspects involve decisions already approved for hospital admission.

According to the CMS final rule, after approving a hospital admission, a Medicare Advantage plan cannot simply reopen and modify that decision based on information obtained subsequently, except in limited situations, such as... obvious error or fraud.

In practice, this change seeks to protect the beneficiary against subsequent reclassifications that could generate uncertainty about coverage or financial responsibility.

Why is this change relevant?

A change after authorization can cause real problems for the patient, the hospital, and the health plan. For example, it can generate unexpected bills, delays in payment processing, and uncertainty about who should pay for a particular service.

However, this rule does not mean that all hospitalizations will be approved. It mainly applies to decisions that the plan has already authorized.

Therefore, the beneficiary must keep:

• Letters of approval;
• messages from the plan;
• protocol numbers;
• authorization records;
• Hospital documents;
• Explanations of benefits;
• any subsequent refusal.

These documents may be useful if there is a dispute or need for an appeal.

Changes to appeal rights

CMS has also taken steps to close gaps in Medicare Advantage appeals processes.

The rule clarifies that a decision made during care may also be considered a coverage decision subject to notification and appeal rules.

This is important because a negative response can occur at different times:

• before the appointment;
• while the beneficiary receives the service;
• after the service has been provided.

Furthermore, when a professional or provider makes a request on behalf of the beneficiary, the plan must communicate the decision to the beneficiary and the provider, as applicable.

Another relevant point is that the beneficiary's financial responsibility should not be determined before the plan makes a decision on the payment request submitted by a contracted provider.

What to do when you receive a negative response?

Upon receiving a coverage denial, the beneficiary should act proactively. First of all, read the entire letter from the health plan and look for the reason for the decision.

After that, check:

• Which service was denied?
• whether the refusal occurred before, during, or after the appointment;
• What is the deadline for appealing?
• What documents can help?
• If the doctor or hospital can provide justification;
• If there is an option for expedited processing;
• Which official channel should be used?

In addition, it's a good idea to keep copies of all documents. If the situation is confusing, the beneficiary can seek guidance from Medicare, the plan, or a free SHIP advisor.

Risk adjustment model update

The CMS concluded in 2026 the gradual implementation of the risk adjustment model officially known as 2024 CMS-HCC Risk Adjustment Model.

Risk adjustment is used to estimate expected healthcare costs for participants and to calculate payments to Medicare Advantage plans. Therefore, this is an important change to the system, but it should not be interpreted as a direct and equal change for all beneficiaries.

The transition occurred gradually:

• starting in 2024;
• continuation in 2025;
• Completion in 2026.

CMS projected that the policies finalized for 2026 would result in an average increase of 5,06 % in government payments to Medicare Advantage plans, equivalent to more than US $ 25 billion in additional payments to the system.

However, this does not mean that each beneficiary will receive higher benefits, lower premiums, or reduced costs. This is an average projection of payments to the plans, not an individual guarantee.

Updates for Medicare and Medicaid beneficiaries

The CMS also updated the rules applicable to Plans for Special Needs of People with Medicare and Medicaid, officially known as D-SNPs.

These plans serve people who have both Medicare and Medicaid coverage. Generally, they aim to coordinate coverage, benefits, and care for beneficiaries with more complex needs.

The final rule established requirements that certain plans must implement by 2027, including:

• Integrated card for Medicare and Medicaid benefits;
• Integrated health risk assessment;
• greater coordination between programs;
• Clearer rules for plans that serve people with dual eligibility.

In addition, the CMS codified deadlines for Special Needs Plans to conduct health risk assessments and develop individualized care plans.

What does that change in practice?

For Medicare and Medicaid beneficiaries, the integration can make navigating between the two programs easier. Still, the actual experience depends on the state, the type of Medicaid, the plan available, and the provider network.

Therefore, those with Medicare and Medicaid should check:

• If the plan accepts your Medicaid category;
• Which doctors participate in the network?
• If the medications are covered;
• How does care coordination work?
• Which additional benefits require specific eligibility?
• whether it involves transportation, credit for products sold without a prescription, dentistry, vision, or healthy foods;
• Which services require prior authorization?

In addition, beneficiaries can contact their state's SHIP service to understand their options without relying solely on marketing materials.

Updates to the star rating in 2026

A Medicare star rating It rates plans from one to five stars and helps beneficiaries compare Medicare Advantage plans and Part D plans.

These ratings consider quality and performance in different areas. Furthermore, the star rating can also affect quality bonus payments to plans.

For 2026, the CMS has adjusted some of the system's measures and weights. Therefore, beneficiaries should understand that the star rating is helpful, but should not be the sole selection criterion.

How does the star rating system work?

Medicare Advantage contracts with drug coverage can be evaluated on several measures. These measures analyze aspects such as:

• preventive care;
• control of chronic diseases;
• patient experience;
• complaints;
• access to care;
• customer service;
• Safety in the use of medications;
• health outcomes;
• quality of plan administration.

In general, more stars indicate better performance in certain metrics. However, a highly rated plan may still not be ideal for a specific person.

What has changed in the 2026 star ratings?

One important change was the reduction in the weight given to measures related to patient experience, complaints, and access. These categories had a weight of four and were reduced to a weight of two.

The measure of assessment of kidney health for patients with diabetes, officially known as Kidney Health Evaluation for Patients with Diabetes.

In addition, two measures were reinstated in the system after changes to their specifications:

• maintaining or improving physical health;
• maintaining or improving mental health.

In 2026, these two measures have a weight of one. The forecast indicated by the CMS is that they will have a weight of three in the 2027 star rating.

Is a plan with more stars always better?

Not necessarily. Star ratings help with comparison, but they don't replace individual analysis.

Before choosing a plan, the beneficiary should also check:

• doctors in the network;
• available hospitals;
• Medication coverage;
• preferred pharmacies;
• copayments;
• cost sharing;
• annual spending limit;
• rules for prior authorization;
• Referral to specialists;
• Extra benefits that are actually available;
• Off-network coverage, if applicable.

A plan may have a good overall rating and still not cover an important medication or include the beneficiary's doctor.

Rules for supplemental benefits in 2026

Supplemental benefits are one of the most publicized parts of Medicare Advantage plans. Depending on the plan, they may include dental, vision, hearing, transportation, fitness programs, telehealth, over-the-counter products, meals, and healthy food benefits.

However, the extra benefits vary considerably. Furthermore, some of them may depend on specific eligibility criteria.

In 2026, the CMS established new limitations for the Special supplementary benefits for people with chronic illnesses., officially known as SSBCI.

What are special supplemental benefits for chronic diseases?

These benefits are special resources that some plans may offer to certain participants with chronic illnesses.

They may be offered unevenly. In other words, not all plan members necessarily receive the same benefit.

Eligibility may depend on:

• Eligible chronic condition;
• health assessment;
• plan criteria;
• health needs;
• type of plan;
• region;
• documentation;
• Insurance company rules.

Furthermore, the benefit must have a reasonable expectation of improving or maintaining health, preserving functional capacity, or supporting quality of life related to the chronic condition.

Which items have been banned as special benefits?

The 2026 rule formalized examples of items that cannot be offered as special supplemental benefits for people with chronic illnesses.

Among them are:

• foods considered unhealthy;
• alcoholic beverages;
• tobacco products;
• life insurance.

The goal is to ensure that special benefits for people with chronic illnesses are reasonably related to health, function, or quality of life.

Does this mean the food benefit is over?

No. The 2026 rule does not mean that all food benefits have ended.

Some plans may continue to offer healthy food benefits to qualified participants. However, these benefits must adhere to rules, limits, eligibility criteria, and lists of permitted items.

In practice, the benefit for food, referred to in some materials as Grocery AllowanceIt may continue to depend on:

• specific plan;
• county;
• chronic condition;
• health assessment;
• Enrollment in D-SNP or another eligible plan;
• Participating suppliers;
• List of approved foods;
• Insurance company rules.

Therefore, beneficiaries should not assume they will receive a food card simply because they have Medicare Advantage.

What should I confirm before trusting this benefit?

Before choosing a plan based on healthy food, confirm:

• Who is eligible?
• What is the value?
• whether the balance is monthly, quarterly, or annual;
• if the value expires;
• What foods are allowed?
• Which stores are participating?
• if there is a need for a chronic condition;
• If the benefit appears in the Benefits Summary;
• If the benefit remains available during the year of the plan.

Furthermore, be wary of advertisements that promise free money to any Medicare beneficiary.

Rules for insulin and vaccines in Part D

As Changes to Medicare Advantage in 2026 They also relate to Part D rules, especially for Medicare Advantage plans that include medication coverage.

For vaccines recommended by Advisory Committee on Immunization PracticesFor vaccines known as ACIP vaccines, and covered by Part D, the deductible should not be applied and there should be no cost sharing.

For covered insulin, the monthly cost must be the lower of the following values:

• US$ 35;
• 25% of the maximum fair price, when applicable;
• 25% of the negotiated price of the medication.

These protections may be relevant for beneficiaries who use medications covered by Part D. However, beneficiaries should still check their plan's list of covered medications, the pharmacy they use, and the applicable rules.

Medicare Prescription Drug Payment Program in 2026

O Medicare Prescription Drug Payment Program It allows Part D participants to distribute certain out-of-pocket expenses for medications throughout the year.

This program began in 2025 and continued into 2026. The final rule for 2026 established the automatic renewal of participation for the following year, unless the beneficiary decides to opt out.

However, it is crucial to understand that this program does not reduce the total price of the medicationIt simply allows you to split certain costs over the months, instead of paying everything at the time of pickup at the pharmacy.

When can this program help?

The program can help people who would otherwise have high expenses concentrated at the beginning of the year. By spreading payments out, it can make monthly budgeting easier.

On the other hand, it is not a discount, extra subsidy, or debt forgiveness. Therefore, before participating, the beneficiary must understand:

• Which medications are included in the calculation?
• how the monthly fees will be charged;
• What happens if I change plans?
• How to exit the program;
• whether participation will be renewed;
• How to track charges.

If in doubt, it's best to speak with your health plan, Medicare, or a SHIP advisor.

Annual spending limit for Part D in 2026

The CMS published final instructions for the redesign of Part D in 2026. Among the points highlighted is the annual limit on out-of-pocket expenses for medications covered by Part D.

For 2026, the annual limit on out-of-pocket spending by Party D was set at US$ 2.100.

This amount is an update to the 2025 limit, adjusted according to applicable rules. However, it refers to medications covered by Part D and does not mean that all of the beneficiary's healthcare expenses will be limited to this amount.

Therefore, the beneficiary must differentiate:

• expenses for medications from Part D;
• Medical costs for Part A and Part B;
• Medicare Advantage copayments;
• Off-grid expenses;
• Services not covered;
• supplementary benefits with their own limits.

Changes in marketing and consumer protection

Consumer protections in 2026 are not limited to advertising. They also appear in rules regarding admission decisions, appeal rights, communication of denials, financial responsibility, transparency of benefits, and limits on supplemental benefits.

The CMS aims to ensure that beneficiaries receive clearer information and have access to appeal processes when a plan decision affects coverage or payment.

Beware of advertisements promising benefits.

Medicare Advantage advertisements may highlight benefits such as:

• card for purchases;
• Products sold without a prescription;
• food;
• transport;
• dentistry;
• glasses;
• Hearing aids;
• reduction of the Part B premium;
• academy;
• Benefits for chronic conditions.

However, these advertisements may not explain all the conditions.

Before providing personal data or requesting registration, please confirm:

1. Is the plan available in your US zip code?
2. Who is eligible for the benefit?
3. Is the payment monthly, quarterly, or annual?
4. Does the balance expire?
5. What products or services are accepted?
6. Does the benefit require a chronic condition?
7. Are your doctors online?
8. Are your medications covered?
9. What is the annual spending limit?
10. Which services require prior authorization?

Never choose a plan solely based on the advertised cost of an extra benefit.

How to identify reliable information

The recipient should be wary of messages, advertisements, or calls that promise benefits without verifying basic information.

Warning signs include:

• to state that every beneficiary will receive money;
• promising benefits without verifying the US zip code;
• Ask for your Medicare number immediately;
• Press to register immediately;
• to claim to represent the government without proof;
• to ensure that a given plan is the best one;
• Hide network information;
• Do not explain co-payments or authorizations;
• to publicize benefits that do not appear in official documents.

The safest course of action is to confirm information from official sources and plan documents.

Important dates for enrolling in Medicare Advantage

Enrollment dates remain crucial for anyone wishing to join, switch, or leave a Medicare Advantage plan.

Annual registration period

O annual Medicare enrollment period It happens every year between October 15th and December 7th.

During this period, the person may, depending on their situation:

• Join a Medicare Advantage plan;
• Change your Medicare Advantage plan;
• to leave Medicare Advantage;
• Return to Medicare Original;
• To enroll, change, or cancel a medication plan.

The changes typically take effect in January 1st of the following year.

For coverage in 2026, the annual period occurred as follows: October 15, 2025 to December 7, 2025.

Medicare Advantage enrollment period open.

People who are already enrolled in Medicare Advantage have a different transition period: January 1st to March 31st.

During this period, it is usually possible to:

• Switch to another Medicare Advantage plan;
• to leave Medicare Advantage;
• Return to Medicare Original;
• Enroll in a Part D plan when returning to Medicare Original.

However, this period is not suitable for anyone to join Medicare Advantage for the first time.

Initial registration period

The initial period usually lasts seven months:

• three months before the month in which the person turns 65;
• the month of your birthday;
• Three months later.

The person can use this period to initiate their Medicare coverage and, when eligible, choose Medicare Advantage.

Special registration periods

Certain events can create a special registration period.

Examples include:

• change of residence;
• loss of other coverage;
• loss or obtaining Medicaid;
• leaving an institution;
• return to the United States;
• plan termination;
• Incorrect or misleading information;
• Specific changes recognized by Medicare.

The timeframe depends on the event. Therefore, the beneficiary should confirm the situation on Medicare.gov, with their plan, or with a SHIP advisor.

Special enrollment period for five-star plans.

When a five-star plan is available in the region, a person can use the special five-star period to make a change.

This right can normally be used once between December 8th and November 30th of the following year.

Before switching, it's important to check if the new plan includes coverage for medications, doctors, hospitals, pharmacies, and necessary benefits.

Furthermore, switching from a Medicare Advantage plan with medication coverage to a plan without Part D coverage may result in loss of medication coverage and potential future penalties, depending on the situation.

Where to find official Medicare updates

Information about Medicare should be verified from official sources, especially when it involves rules, enrollment, costs, benefits, and coverage.

Medicare.gov

O Medicare.gov This is the official federal government website for Medicare beneficiaries.

In it, you can consult:

• Registration rules;
• coverage;
• costs;
• rights;
• periods of change;
• benefits;
• contacts;
• plan comparison;
• educational materials.

Medicare Plan Finder

O Medicare Plan Finder Allows you to compare available plans by US zip code.

The tool provides information about:

• prizes;
• copayments;
• franchises;
• Medication coverage;
• star rating;
• extra benefits;
• pharmacies;
• estimated costs;
• options available in the area.

However, don't just stop at the summary. Open the detailed documents for each option and confirm the network, medications, and rules.

CMS.gov

O CMS.gov Publishes proposed rules, final rules, announcements, fact sheets, star rating data, payment updates, and regulatory materials.

For definitive information, search for official terms such as:

• final rule;
• final guidance;
• announcement of fees;
• technical specifications;
• Technical sheet for the star rating.

A proposed rule is just that—a proposal. It can be modified, postponed, or not finalized.

How to contact Medicare

For official assistance, the beneficiary can access the page. Speak to someone at Medicare. or the official Medicare contact.

The official phone number is:

1-800-MEDICARE — 1-800-633-4227

TTY users can call:

1-877-486-2048

Before calling, have the following ready:

• Medicare card;
• plan name;
• list of medications;
• Mail received;
• questions noted;
• Billing documents or requests, if the matter involves accounts, payments, or medical records.

Free help via SHIP

O State Health Insurance Assistance ProgramSHIP, also known as SHIP, offers free and unbiased advice about Medicare.

To find the SHIP code for your state, go to... SHIP National.

This support can help you compare plans, understand enrollment periods, review benefits, identify support programs, and avoid decisions based solely on advertisements.

How to revise your plan for 2026

Even if the beneficiary hasn't changed their coverage, it's important to review the plan documents.

Annual notice of changes

O Annual Notice of Changes It tells you what has changed from one year to the next. It may show changes in costs, benefits, network, medications, and rules.

Summary of benefits

O Summary of Benefits It provides a summary of the main costs and benefits. It helps to compare plans, but it is not a substitute for more comprehensive documentation.

Evidence of coverage

A Coverage Evidence It explains in detail how the plan works. In general, it outlines rules, limits, exclusions, costs, and appeal processes.

Provider directory

O Provider Directory It shows doctors, hospitals, and other providers in the network. However, it's still worth confirming directly with the plan and the doctor's office, as networks can change.

List of covered medications

A List of Covered Medications It outlines covered medications, cost categories, restrictions, prior authorization requirements, the need to test another medication beforehand, and quantity limits.

Medicare Plan Finder

Medicare Plan Finder allows you to compare your current coverage with other options available by U.S. zip code. Therefore, it should be used in conjunction with your plan documents.

Questions to ask before keeping or changing your plan.

Before keeping or changing a Medicare Advantage plan, the beneficiary should answer some practical questions.

The main ones are:

• Are my doctors still on the network?
• Is my preferred hospital still covered?
• Are my medications still on the list of covered medications?
• Has any medication changed cost category?
• Has the monthly bonus increased?
• Have the copayments changed?
• Has the franchise changed?
• Has the annual spending limit increased?
• Have dental benefits been reduced?
• Has the tax credit for goods sold without revenue changed?
• Is the food benefit still available?
• Does any service now require prior authorization?
• Has the star rating changed?
• Does the plan still cover my US zip code?
• Is there another plan that would be more suitable for my situation?

Additionally, those receiving Medicaid, Extra Assistance, or participating in a plan for special needs should check specific rules before changing plans.

Common Mistakes When Interpreting Changes to Medicare Advantage in 2026

To assume that every plan will have the same benefits.

Federal rules set standards and limits, but each plan still has its own characteristics. Therefore, two plans in the same state may offer different benefits.

To think that the benefit for food is automatic.

Food benefits may depend on plan, region, chronic condition, Medicaid, or other rules. Not all beneficiaries receive this benefit.

Treating increased payments to health plans as a personal increase.

The average increase projected by CMS in payments to plans does not guarantee cost reductions or increased benefits for each individual.

Choosing a plan based solely on the stars

Star ratings help with comparisons, but they don't replace analysis of doctors, medications, hospitals, costs, and access rules.

Ignore official plan documents.

Advertisements may highlight advantages, but official documents explain limits, exclusions, values, and conditions.

Confusing proposal with final rule

Not every CMS proposal becomes a rule. Therefore, decisions should consider final documents, not just news reports about proposals.

Conclusion

As Changes to Medicare Advantage in 2026 These changes brought relevant updates for beneficiaries, plans, and providers. Key points include new protections for certain already approved hospitalizations, adjustments to recourse rights, clearer rules for supplemental benefits, changes to star ratings, updates to plans for people with Medicare and Medicaid, the continuation of the Medicare Prescription Drug Payment Program, and important rules related to Part D.

However, these changes do not make all plans the same. Costs, networks, medications, extra benefits, and authorization rules continue to vary by plan, insurer, and county.

Therefore, the best decision should not be based solely on advertisements, benefit cards, or star ratings. The beneficiary should compare plans on Medicare Plan Finder, read official documents, confirm doctors and medications, and seek help from Medicare or SHIP when necessary.

In summary, the 2026 updates may strengthen protections and improve clarity in some areas, but the choice of plan remains individual. Before maintaining, changing, or contracting coverage, confirm everything through official sources and the specific plan documents.

Frequently asked questions about Medicare Advantage in 2026

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This content is for informational purposes only. It does not replace official guidance, does not guarantee eligibility, does not confirm individual benefits, and does not determine which plan is best for each person. Benefits, costs, networks, and rules may vary depending on the plan, the insurer, the county, and the beneficiary's situation.