What's New in Medicare

Every year, Medicare Part D and Medicare Advantage plans make changes to their plans, such as copay costs, what prescriptions are covered, and what pharmacies and providers are in network.  Plan changes go into effect January 1, creating questions about how to navigate these changes:   

What should I do if my provider is no longer in network with my Medicare Advantage plan? 

If you discover that your healthcare provider is no longer in network with your Medicare Advantage plan this year, you have some options:

1. Check with Your Plan: If your Medicare Advantage plan is a PPO, it may allow you to see out-of-network providers for a higher cost, as long as the provider also accepts the plan. Check with the plan to see what copays you would have if you stay with that provider.  If you are currently receiving treatment for an acute, serious, or chronic condition and your provider is now out-of-network, you can request limited-time “continuity of care” from any Medicare Advantage plan. This will allow you to continue receiving care at in-network costs, but your Medicare Advantage plan decides if they will approve the request based on your situation.
2. Switch Providers: Search your Medicare Advantage plan’s website or call the customer service phone number on your plan card and ask them to help you find a different in-network provider.
3. Switch Plans: If you want to keep your provider, take advantage of the Medicare Advantage Open Enrollment Period (MA-OEP) from January 1 to March 31 to change your plan. During this time, you can make one change by switching to a different Medicare Advantage plan or returning to Original Medicare Parts A & B by enrolling in a Part D plan.
   
   If you make changes during the MA-OEP from January 1 to March 31:
   1. Changes won’t take effect until the start of the following month, so you may need to delay appointments until the new plan goes into effect.
   2. If you do decide to switch from Medicare Advantage to Original Medicare, you will want to have a plan for secondary or supplemental coverage to help with the costs that Original Medicare Parts A & B do not cover.
4. Contact Medicare at 1-800-633-4227 if you were given incorrect provider information through the medicare.gov provider directory: Starting in October 2025, Medicare.gov now lists which providers are in-network with Medicare Advantage plans. If you enrolled in a plan because medicare.gov listed your provider as “in network” and you later find out they aren’t, you can call Medicare to switch plans, as long as it’s within three months of when your plan started.    

Medicare Advantage Tips: To avoid unexpected expenses, contact your provider before appointments to confirm they accept your plan.  We also recommend reviewing your plan’s Evidence of Coverage document which outlines benefits, copays, rules, etc., for this year.  You can find an Evidence of Coverage document on the plan’s website or you can call your plan and request one.   

What if my Medicare Advantage plan was canceled?

If your Medicare Advantage plan was canceled at the end of 2025 and you did not enroll in a new plan before December 31, 2025, you might be without full coverage. In this case, you have two options:

1. Enroll in a New Medicare Advantage Plan: Find a plan that covers your preferred providers and prescriptions. You have until February 28, 2026, to enroll in a new plan because your previous plan was cancelled.  The new plan will begin the start of the month following your enrollment.
2. Return to Original Medicare: If your Medicare Advantage plan was cancelled, you have a limited-time window for a “guaranteed issue” opportunity to sign up for a Medicare Supplement (Medigap policy) by February 28, 2026, without underwriting. This means the insurance company must sell you a Medicare Supplement policy at the best available price, regardless of your health conditions.  You will also need to enroll in a standalone Medicare Part D plan for drug coverage by February 28, 2026, to go with Original Medicare Parts A & B (unless you have other creditable drug coverage).  

What if my prescription is no longer covered by my drug plan?

If you find that your prescriptions are not covered or have increased in cost, consider these steps:

1. Check Pharmacy Options: Ensure your pharmacy is preferred and in-network with your plan. This information is available on Medicare.gov or by contacting your plan's customer service phone number on your card.
2. Consult Your Provider or Pharmacist: Discuss potential alternative medications that are covered by the plan. If necessary, your provider can try to request a formulary exception from the plan or help you find possible prescription assistance programs.
3. Consider Changing Plans: If your prescription needs change and you are enrolled in a Medicare Advantage plan, you can use the Medicare Advantage Open Enrollment Period (January 1 to March 31) to switch to a plan that could cover all your prescriptions.

Medicare Part D Tip: If you are enrolled in a standalone Part D plan, you can switch plans any month of the year if you have Extra Help (also called LIS- low-income subsidy) prescription assistance.

I’m taking one of the drugs that’s on the list of Medicare negotiated drugs this year.  Do I need to do anything to activate those savings?

In 2026, anyone enrolled in a Medicare drug plan (whether it is through a standalone Part D plan or a Medicare Advantage plan) will have reduced costs on Eliquis, Jardiance, Xarelto, Januvia, Farxiga, Entresto, Enbrel, Imbruvica, Stelara, and NovoLog/Fiasp.  If your drug plan covers the prescription, you should see reduced costs when you fill these prescriptions, meaning that you don’t need to apply for savings or use a specific coupon to take advantage of the reduced costs.

Anyone who has Medicare drug coverage in 2026 will also have a $2,100 cap on drug costs, as long as all your prescriptions are covered by the drug plan. The $2,100 cap does not include your drug plan premium or prescriptions that do not go through your drug plan (such as prescriptions that aren’t covered by your plan or by Medicare, or prescriptions you pay for with a discount coupon, etc.).

What else should I remember as the new year begins?

Open & respond to all your mail: This is how CMS (Centers for Medicare & Medicaid Services), Medicare Advantage and Part D plans, Social Security, and Medicaid (Health & Human Services) will notify you of any important changes in your coverage.   

Pay your plan premiums: Make sure your plan premium for any Medicare Part D plans or Medicare Advantage plans are being paid through your Social Security benefit or that you are directly paying the plan. If you aren’t sure, call the customer service number on your plan card to check so you are not disenrolled from the plan due to missed premiums.

Plan premium payment Tips: Regularly review your accounts to ensure that your plan premiums are being paid- even if you have set up automatic payments. Having your premiums paid directly through your Social Security benefit provides the most protection against payment errors. If there is a banking error and the bank fails to pay your premiums you could still be disenrolled from your plan for nonpayment due to no fault of your own.

Note about plan premiums: Wellcare Value Script (Medicare Part D plan) had a $0 premium in 2025 and has a $9.60/month premium in 2026. Pay attention to any notices they send you in the mail about paying plan premiums now, or make sure the premium is coming out of your Social Security check this year.      

For any additional questions, please reach out to SHIIP/SMP at 1-800-351-4664 and we can connect you with your local site. Or you can call 1-800-MEDICARE (1-800-633-4227).