Medicare Made Simple

New Electronic Prior Authorization Rules for Medicare Advantage: Starting in January 2026, the new CMS Interoperability and Prior Authorization Rule (CMS-0057-F) will take effect for Medicare Advantage plans. This mandate requires plans to use electronic prior authorization (ePA) and standard APIs to accelerate decision times and improve data exchange. Standard prior authorization requests must now be completed within 7 days, and expedited requests within 72 hours. Plans will also be required to provide specific, structured denial reasons and publish overall decision-time metrics. Reference: What Is the CMS 2026 Prior Authorization Rule?

Restrictions on Revoking Approved Inpatient Admissions: The newly finalized Contract Year 2026 Medicare Advantage rule restricts the ability of plans to reopen and modify previously approved inpatient hospital decisions. Once a Medicare Advantage plan approves an inpatient admission, it must honor that prior authorization. Plans can now only reopen an approved admission in cases of obvious error or fraud, providing more certainty for patients and healthcare providers. Reference: Contract Year 2026 Policy and Technical Changes

Uncertainty Around Internal Coverage Criteria for Advantage Plans: While CMS strengthened some provider appeals processes for 2026, the agency deferred finalizing a strict definition for “internal coverage criteria” in Medicare Advantage plans. This delay leaves some ambiguity regarding how plans can apply their own utilization management rules versus following traditional Medicare guidelines. Advocacy groups are keeping a close watch on this, as it impacts how and when plans can deny medically necessary care. Reference: CMS Releases Final 2026 Medicare Advantage Rule

Medigap Plans Remaining Intact for 2026: Despite rumors circulating during the enrollment season, Medicare Advantage is not replacing Medicare Supplement (Medigap) plans in 2026. Medigap policies—such as Plan G and Plan N—will continue to operate as usual, though standard annual rate adjustments will apply. Additionally, the out-of-pocket limits for the cost-sharing plans have been updated for 2026: Plan K’s limit is now $8,000, and Plan L’s limit is $4,000. References: 2026 Guide to Medicare Plans | Are Advantage Plans Replacing Medigap?

2026 Medicare Part D Prescription Caps: Under the finalized 2026 guidelines, the Medicare Part D out-of-pocket cap for prescription drugs is officially set at $2,100 annually. Once a beneficiary reaches this threshold, they will not owe copayments or coinsurance for covered Part D drugs for the rest of the year. In addition to the $2,100 limit, the $35 monthly cap on insulin remains in place, and ACIP-recommended adult vaccines will continue to be covered at no cost. Reference: Medicare and You Handbook 2026