MedStar Insurance Agency· MedStar Insurance Agency · Medicare · 3 min read
2025 Summer Updates
News and updates looking into 2026: Here’s what what were looking forward to in the coming year.
📜 Contract Year 2026 MA‑Part D Final Rule (Final Rule Highlights)
- Inpatient admission decisions: Once a hospital stay is pre-approved, MA plans cannot later rescind it unless there’s clear evidence of error or fraud, improving stability in care coverage (Centers for Medicare & Medicaid Services).
- Dual-eligible plans (D‑SNPs) & star ratings: Adjustments to how risk data is reported and evaluated continue, including tweaks to HCC coding and risk adjustment for D‑SNP plans (Mintz).
- Supplemental benefits limits (SSBCI): CMS codified a non‑exhaustive list of non‑health‑related items that MA plans cannot offer as supplemental benefits under SSBCI guidelines (Kiplinger).
💊 Part D & Prescription Payment Plan Updates
- The Medicare Prescription Payment Plan (MPPP), allowing spread-out drug cost billing, will now be automatically renewed each year, unless you opt out—and opt-out requests must be processed within three days (Kiplinger).
- The Part D out-of-pocket cap increases to $2,100 in 2026, up $100 from 2025, and will continue to adjust with inflation going forward (Kiplinger).
- Insulin cost-sharing remains capped at $35/month with no deductible, and all adult vaccines recommended by ACIP continue to have $0 cost-sharing under Part D (Kiplinger).
🩺 Access, Appeals & Transparency
- In six states (including Ohio), Original Medicare will begin requiring prior authorizations using a new AI-assisted review model (WISeR). Human clinicians make final decisions, but tech speeds up initial review (Kiplinger).
- Humana (one of MA’s largest insurers) will reduce prior authorization requirements and make approvals faster—starting 2026, they’ll also publish public PA approval/denial rates and timelines (Kiplinger).
🏛️ Policy & Marketing Oversight
- A Senate report (led by Sen. Ron Wyden) calls out MA marketing practices as problematic—advocating for making brokers fiduciaries, limiting commissions, and increasing CMS control over marketing leads and agents (MarketWatch).
- While CMS announced the payment boost, enforcement of tighter broker oversight and marketing reform is still under review (MarketWatch, Better Medicare Alliance).
🏥 Payment Increases & Industry Reaction
- Medicare Advantage payments will increase by ~5.06% in 2026, based on the final CMS rate announcement—this amounts to roughly $25–35 billion in additional funds for MA plans compared to 2025 (Centers for Medicare & Medicaid Services).
- As a result, major insurers like UnitedHealth, Humana, and CVS saw their stock values rise—Humana gained ~12% and CVS about 7% (AP News).
📋 Summary Table
| Area | 2026 MA Highlights |
|---|---|
| Government Payments | +5% payment bump to MA plans (≈$25–35B more) |
| Inpatient Admissions | No reversal except in fraud/error cases |
| Prescription Coverage (Part D) | Automatic MPPP renewal; $2,100 OOP cap; $35 insulin cap; free vaccines |
| Prior Authorizations | Trimmed by Humana; Original Medicare adds PA in 6 states |
| Supplemental Benefits | Stricter limits on non‑health benefits under SSBCI |
| Marketing Reform | Senate calls for reforms; CMS reviewing oversight changes |
✅ Key Takeaways for Seniors
- Expect new or revised benefits: Part D drug caps, protected coverage of vaccines/insulin, and smoother billing through MPPP.
- Better stability on hospital stays and less uncertainty from PA denials in MA plans.
- Increased transparency: Humana and others will share PA performance data.
- Stay alert to potential marketing changes: Ongoing scrutiny means agent practices may evolve in coming years.
Share:
