Medicare Advantage plans are not going away, but they are facing significant changes that could affect coverage and costs. With important exceptions regarding eligibility and benefits, beneficiaries must stay informed to navigate these evolving options.
As Medicare Advantage plans continue to evolve, beneficiaries must be aware of the changing landscape that could impact their healthcare choices. The rules are stricter than many expect, particularly regarding coverage limitations and costs, making it essential for seniors to understand their options and prepare for potential disruptions as they navigate these updates.
Key Takeaways
- Medicare Advantage plans exclude benefits for alcohol, cannabis, and cosmetic surgeries.
- The Part D out-of-pocket cap is set at $2,100 annually, while Part B premiums increase to $202.90/month.
- Beneficiaries must be enrolled in Original Medicare Parts A and B to qualify for Medicare Advantage.
- Funding for Medicare Advantage increases by 4.3%, despite some insurers exiting the market.
- Special Enrollment Periods are available for life changes like moving or losing coverage.
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Understanding Coverage Limitations in Medicare Advantage Plans
Exclusions from Supplemental Benefits
Medicare Advantage plans come with specific exclusions that beneficiaries should be aware of. Notably, these plans do not cover alcohol, cannabis, cosmetic surgeries, funeral costs, life insurance, tobacco products, or unhealthy foods, which can limit the support available for certain health and lifestyle choices.
Vaccines and Core Benefits
Beneficiaries can take comfort in knowing that Medicare provides free coverage for recommended adult vaccines, with no deductible or co-pay required. Additionally, the core benefits of Medicare Part A, B, and Part D remain unchanged, ensuring that essential healthcare services continue to be accessible.
Extra Benefits Offered
Many Medicare Advantage plans enhance their offerings by providing additional benefits such as vision, hearing, and dental coverage. For instance, Anthem plans include not only prescription drug coverage but also allowances for healthy foods and utilities, catering to a broader range of health needs.
Navigating Increased Costs in Medicare
Annual Out-of-Pocket Caps and Premiums
As costs rise, beneficiaries must be prepared for increased premiums and out-of-pocket expenses. The standard premium for Part B will increase to $202.90 per month, reflecting a $17.90 rise from 2025, while the annual out-of-pocket cap for Part D is set at $2,100.
Deductibles and Premium Adjustments
In addition to premium increases, beneficiaries will see adjustments in deductibles. The Part B deductible will rise to $283, an increase of $26 from the previous year, and the Part A deductible will increase to $1,736, up by $60, impacting overall healthcare costs.
Changes in Drug Costs
Beneficiaries will experience some relief as the in-network out-of-pocket maximum decreases to $9,250 from $9,350. Furthermore, adjustments to insulin cost caps and indexing of Part D expenses for inflation aim to alleviate some financial burdens on seniors.
Key Exceptions Impacting Medicare Advantage Enrollees
Plan Switching and Availability Issues
Beneficiaries misled by the plan finder tool have the opportunity to switch plans during a special enrollment period, ensuring they can find a suitable option. However, in Alaska, 106,000 beneficiaries currently have no available Medicare Advantage plans, highlighting significant gaps in coverage.
Market Exits and Coverage Disruptions
The landscape for Medicare Advantage is shifting, with an increasing number of enrollees facing plan terminations in 2026. Notably, 14 health systems are dropping Medicare Advantage plans due to reimbursement issues, potentially disrupting coverage for many beneficiaries.
Changes in Plan Requirements
Changes are also occurring within specific plans, such as UnitedHealthcare’s decision to exit 225 counties while entering 14 new ones. Starting January 1, 2026, HMO/POS plans from UnitedHealthcare will require referrals, adding another layer of complexity for enrollees.
Eligibility Criteria for Medicare Advantage Plans
Basic Eligibility Requirements
To qualify for Medicare Advantage plans, individuals must be eligible or enrolled in Original Medicare Parts A and B. Additionally, those aged 65 and older with fewer than 40 quarters of work will be required to pay a premium for Part A.
Enrollment Periods
The Initial Enrollment Period for Medicare spans seven months around an individual’s 65th birthday, allowing for timely enrollment in both Original Medicare and Medicare Advantage. Following this, the Annual Enrollment Period occurs from October 15 to December 7 each year, providing another chance for beneficiaries to review their options.
Special Enrollment Opportunities
Beneficiaries experiencing significant life changes, such as moving or losing existing coverage, may qualify for Special Enrollment Periods. These opportunities ensure that individuals can adjust their plans as needed, maintaining access to necessary healthcare services.
Recent Updates Affecting Medicare Advantage Plans
Funding and Coverage Changes
Despite some insurers exiting the market, Medicare Advantage funding is set to increase by 4.3%, which may help sustain coverage options for beneficiaries. Additionally, the Centers for Medicare & Medicaid Services (CMS) has codified exclusions for Special Supplemental Benefits for the Chronically Ill, further defining the scope of available benefits.
Streamlining for Dual-Eligible Beneficiaries
In a move to simplify access, dual-eligible D-SNPs will streamline with uniform ID cards by 2027, with early adaptations expected in 2026. This initiative aims to enhance the experience for beneficiaries who qualify for both Medicare and Medicaid.
Pilot Programs and Automatic Renewals
A new pilot program for prior authorizations in Original Medicare will begin in 2026, potentially improving the efficiency of care approvals. Additionally, beneficiaries will experience automatic renewal for the Medicare Prescription Payment Plan unless they opt out, ensuring continuity in their coverage.
Essential Tips for Medicare Advantage Enrollees
Preparing for Open Enrollment
As the open enrollment period approaches, beneficiaries should review their plan’s Evidence of Coverage for any changes in benefits for 2026. It’s also crucial to check for any plan terminations or consolidations to avoid disruptions in coverage.
Ensuring Continuous Coverage
When starting new Medicare Advantage coverage, verifying that providers are in-network is essential to ensure access to necessary services. Additionally, coordinating enrollment to begin on the first day of the birthday month can help maintain continuous coverage.
Evaluating Coverage Options
During the Annual Enrollment Period, beneficiaries should carefully evaluate their coverage options, considering the changes coming in 2026. It’s important to take into account the implications of market exits and adjustments to plans to make informed decisions.
Implications of Medicare Changes for Beneficiaries
The updates coming in 2026 bring significant implications for Medicare beneficiaries, particularly regarding restrictions on supplemental benefits and increased costs. As these changes unfold, beneficiaries must prepare for potential disruptions in their coverage options, ensuring they remain informed and proactive in managing their healthcare.