Millions of Medicare beneficiaries, including five million in Florida, are set to face significant adjustments to their health coverage in 2026. These changes will affect plan availability, monthly premiums, prescription drug costs, and out-of-pocket expenses, requiring enrollees to carefully review their options during the upcoming open enrollment period.
Key Takeaways
- Medicare Advantage Plans: Many enrollees will see reduced plan choices, shifting provider networks, and potentially higher costs for services like hospital stays.
- Original Medicare Costs: The monthly premium for Medicare Part B is projected to see a double-digit increase, rising by 11.6% to approximately $206.50.
- Prescription Drug Plans (Part D): The out-of-pocket maximum for prescription drugs will increase by $100, rising from $2,000 in 2025 to $2,100 in 2026.
- Prior Authorization: New rules aim to simplify the prior authorization process, requiring faster responses from insurers and clearer reasons for denials.
Medicare Advantage Plans See Market Shifts
The landscape for Medicare Advantage plans is contracting in 2026. Many insurance carriers are reducing their service areas, leading to fewer plan options in certain regions. This means some beneficiaries may find their current plan is no longer available next year.
Gloria Ayan, a liaison with the SHINE counseling center in Broward County, Florida, noted that many local enrollees with plans from Humana, Care Plus, and AvMed have received notices that their current plans will be discontinued in 2026.
These shifts also impact provider networks. Some individuals have been informed that their preferred hospital system or affiliated doctors will no longer be in-network. Health insurance expert Jenny Chumbley Hogue advises beneficiaries to be proactive.
"If a doctor or other provider is important to you, do not rely on online directories," Hogue stated. "Call and ask which plans they are participating in for 2026."
Rising Out-of-Pocket Costs and Reduced Perks
Beyond network changes, enrollees may face higher direct costs. Some Medicare Advantage plans are increasing the total out-of-pocket maximum for inpatient hospital care. Others are raising daily co-pays for hospital stays.
"You don’t want it to be a surprise if your hospital co-pay increases $75 a day and you’re in the hospital for four days," said Louise Norris, a health policy analyst for medicareresources.org. She emphasized that such unexpected costs can accumulate quickly.
Additionally, popular supplemental benefits, often used to attract new members, are being scaled back. Perks such as grocery cards, transportation to medical appointments, and fitness programs may have new spending caps or be reduced in 2026.
Florida's Medicare Advantage Landscape for 2026
According to the Centers for Medicare & Medicaid Services (CMS), Florida will have 611 Medicare Advantage plans in 2026, a slight decrease from 613 in 2025. Despite this, 100% of beneficiaries will have access to a Medicare Advantage plan, with all having the option of a plan with a $0 monthly premium. The average monthly premium is expected to decrease to $2.11.
Original Medicare Premiums and Drug Costs Increase
Beneficiaries enrolled in Original Medicare will also see their costs rise. The most significant change is a projected 11.6% increase in the standard Medicare Part B premium, which is expected to reach $206.50 per month.
Tricia Neuman, executive director for KFF’s Program on Medicare Policy, explained the reason for the hike. "Premiums are based on spending, so as spending rises, premiums have gone up," she said. Despite the higher cost, Neuman highlighted the benefits of Original Medicare, such as the freedom to see any doctor in the country without needing prior authorization.
Changes to Part D Prescription Drug Plans
Prescription drug coverage, whether through a stand-alone Part D plan or as part of a Medicare Advantage plan, is also becoming more expensive. The maximum out-of-pocket cost for covered prescriptions will increase by $100, from $2,000 in 2025 to $2,100 in 2026.
Once a beneficiary reaches this cap, they will not have to pay for covered drugs for the rest of the year. While this limit is a significant improvement from previous years when no cap existed, the upward trend in costs means enrollees should carefully review their plan's formulary to estimate their total medication expenses.
On a positive note, Medicare will continue to provide free coverage for all CDC-recommended adult vaccines in 2026, including those for shingles, pneumonia, flu, and COVID-19 boosters, with no deductible or co-payment required.
Income Threshold for Surcharges to Rise
Higher-income individuals pay a surcharge on their Medicare premiums. For 2026, the income threshold for this surcharge will increase by $3,000 to $109,000 for an individual. This determination is based on the tax return from two years prior (2024). An appeals process is available for those whose financial situation has changed since then.
Procedural and Systemic Updates to Medicare
The federal government is implementing changes aimed at improving the beneficiary experience. One of the most significant updates targets the prior authorization process, a frequent source of frustration for seniors.
Simplifying Prior Authorizations
New rules are designed to streamline approvals for medical care. Key changes include:
- Continuous Approval: Insurer approvals for inpatient hospital care must remain valid until the patient is discharged, eliminating the need for mid-stay re-approvals.
- Faster Responses: Health plans must respond to authorization requests within 14 business days.
- Clear Denials: Any denial of care must be accompanied by a specific clinical reason.
- External Review: Beneficiaries who are denied care have the right to request an independent external review of the decision.
AI and Star Ratings Overhaul
The government is also exploring new technologies to manage costs. A five-year pilot program will launch on January 1, 2026, in six states—not including Florida—to test an AI-powered system for approving or denying care for Original Medicare enrollees. This initiative will be closely watched to see if it saves money or creates new challenges.
Finally, the Medicare Star Ratings system is being updated. The criteria for achieving top ratings will become more stringent, with a greater emphasis on patient satisfaction and the quality of care provided. A 5-star rating indicates the highest quality. This change should make it easier for consumers to identify high-value plans, although experts like Louise Norris suggest using ratings as a final check after narrowing down choices based on personal needs like network and drug coverage.
