Medicare’s 2026 rulemaking is now largely set, and it brings a small host of changes. There are updates to Part D, experiments in traditional Medicare, and adjustments to Medicare Advantage payments and rules. Herein we explore currently known changes, as well as take a look at potential changes which will be finalized later in the fall.
- The Inflation Reduction Act’s Part D overhaul enters its second year in 2026 with concrete parameters. CMS’s final 2026 program instructions set the defined standard deductible at $615 and the annual OOP threshold at $2,100, up from $2,000 in 2025 due to the law’s inflation indexing formula. After that threshold, enrollees pay no cost-sharing for covered Part D drugs. The 2026 guidance also describes how plan, manufacturer, and Medicare liabilities shift once negotiated “maximum fair prices” for selected drugs begin to apply, and it establishes a new selected drug subsidy to align plan payments with those negotiated prices. (CMMS)
- Two IRA cost protections that began earlier are now codified in regulation for 2026 and beyond: ACIP-recommended adult vaccines covered under Part D continue with zero cost-sharing, and insulin remains capped at $35 per month (or lower, depending on negotiated or plan prices), with no deductible. (CMMS)
- CMS has set the Part D base beneficiary premium for 2026 at $38.99 and released the second-year parameters of its Premium Stabilization Demonstration: a $10 uniform reduction to the base, a plan-specific year-over-year premium increase cap of $50 (up from $35 in 2025), and removal of 2025’s narrowed risk corridors. These levers are meant to smooth premiums as plans adapt to the redesigned benefit. Actual premiums still vary by plan and market. (CMMS)
- For Part B, independent reporting based on CMS projections indicates a meaningful jump is expected in 2026—into the $206.50 range monthly—with a higher Part B deductible and IRMAA surcharges also moving up. Those are projections, not final rates, but they signal upward pressure on costs. Final Part B amounts are typically announced later in the year. (Investopedia)
- On the Medicare Advantage side, CMS finalized the 2026 rate announcement, projecting an average 5.06% increase in government payments to plans versus 2025, reflecting a higher effective growth rate and the final year of a technical adjustment phase-in. CMS also continues a multi-year phase-in of risk-adjustment model updates. Payment policy changes are paired with consumer-protection rules in the Contract Year 2026 final rule: MA plans face tighter guardrails around reopening previously approved inpatient admissions (limited to obvious error or fraud), clarified appeals rights (including for concurrent service decisions), and a codified list of non-allowable SSBCI items (e.g., alcohol or non-healthy food) to keep supplemental benefits aligned with health goals.
- For people dually eligible for Medicare and Medicaid, CMS is pushing toward more integrated experiences in certain D-SNPs, including integrated ID cards and unified health risk assessments by 2027, with timing and member-involvement standards for all SNPs. While these D-SNP integration steps land later than 2026, the enabling rulemaking is part of the 2026 package.
- Beginning January 1, 2026, CMS will test the WISeR model (Wasteful and Inappropriate Service Reduction) in six states—Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington—introducing prior authorization or post-service review for select outpatient items and services historically vulnerable to overuse or fraud. WISeR runs for six performance years and uses technology (including AI) to streamline reviews; decisions must ultimately be made by licensed clinicians. The model does not change Medicare’s coverage rules, but it will test whether more front-end review can reduce unnecessary spending without harming access. (Federal Register)
Taken together, 2026 cements the new Part D cost structure—with a higher but still capped OOP maximum, zero-cost vaccines, a persistent insulin cap, and the first effects of drug price negotiation—while plan premiums and Part B costs are poised to move upward. MA plans will enter 2026 with higher average payments but tighter consumer-protection rules, and a subset of traditional Medicare services in six states will face prior authorization scrutiny via WISeR. Enrollees comparing options this fall will see plan materials reflect the $615 deductible and $2,100 OOP threshold for Part D, along with any plan-specific premiums influenced by the stabilization demonstration and the evolving liability mix under the redesign.
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