New doctor directories, updated drug costs, and a pilot run in New Jersey of using artificial intelligence to approve certain procedures are among the changes coming to Medicare in 2026.
Medicare’s open enrollment runs Oct. 15 through Dec. 7. During that time, people should review the details of their current plan — such as which doctors are covered and medication prices — and can make changes to their coverage for 2026.
Medicare is the federally funded health program for people 65 and older, and some people with disabilities. People can enroll in traditional Medicare (Parts A and B), which is administered directly by the government; or Medicare Advantage, which are private plans that contract with the government to provide Medicare benefits.
Enrollment season can be overwhelming: There are dozens of plans to choose from, and seniors are inundated with television and mail advertisements. Scams are abundant, so it is important to be informed about your options and where to go for help.
“When people are confronted with a huge wealth of options, they’re not necessarily better off if they don’t have the bandwidth to deal with it,” said Alex Cottrill, a senior policy analyst at KFF, a nonprofit health policy organization based in Washington, D.C.
With healthcare costs top of mind for many families and seniors, Medicare’s upcoming open enrollment period is an opportunity to make sure your health plan won’t end up costing more than necessary.
The government has not yet released the premium rate for Part B, which covers hospital services and is paid by all enrollees, regardless of whether they enroll in traditional Medicare or an Advantage plan. Premiums typically increase annually.
Other factors, such as prescription medications, also affect how much your plan will cost next year, and are worth reviewing.
A good starting place to learn more is Medicare’s online plan finder tool — https://www.medicare.gov/plan-compare — and the helpline 1-800-MEDICARE (1-800-633-4227). Pennsylvania‘s Medicare Education and Decision Insight office and New Jersey‘s State Health Insurance Assistance Program can also help.
Here are some other changes to be aware of for 2026:
Provider directories for Medicare Advantage plans
Beginning this fall, Medicare’s plan finder tool will allow people shopping for Medicare Advantage plans to check whether their preferred doctors are in network.
Similar to private health insurance, Medicare Advantage plans typically have networks of doctors that they contract with for services. People whose doctors are out-of-network with their Medicare Advantage plan may have to pay a greater share of the bill, or the plan could refuse to cover the visit at all.
More than 60 Medicare Advantage plans are available to Philadelphia seniors, and which doctors are covered can vary.
By comparison, traditional Medicare does not have a provider directory, as very few physicians — about 1% of non-pediatric providers — opt out of Medicare.
There will be a three-month special enrollment period to allow people who use the new provider directories to select a Medicare Advantage plan if they later realize the information was incorrect and their doctor is not in-network. The special enrollment period is intended to create a smoother roll-out for the provider directories, which should be accurate, but can be challenging for insurers to keep up to date.
Higher out-of-pocket max for Part D drug plans
The maximum amount people with a Part D drug plan will have to spend out of pocket is increasing to $2,100 in 2026, up from $2,000. After meeting the cap, you pay $0 for the rest of the year.
New, negotiated prices for 10 high-cost drugs will also take effect in 2026: Januvia, Fiasp, Farxiga, Enbrel, Jardiance, Stelara, Xarelto, Eliquis, Entresto, and Imbruvica. They treat common chronic conditions, such as diabetes, heart failure, blood clots, rheumatoid arthritis, and psoriasis.
Historically, Medicare has not negotiated drug prices the way private insurers do, but as part of the 2023 Inflation Reduction Act, former President Joe Biden and Democrats pushed for greater price control over the 10 drugs that accounted for about 20% of the government’s Part D spending.
The new negotiated rates mean all 10 drugs should be covered by any Part D plan, and that the cost will be the same across plans — making comparing plans a little easier for people who rely on those medications.
These changes apply specifically to people with traditional Medicare who purchase a Part D plan for prescription drugs.
Medicare Advantage plans typically include drug coverage. Check the individual plan for details about its cost-sharing for prescription medications.
The annual enrollment period is an opportunity to review your plan’s drug coverage to be sure it will still pay for needed medications. The list of drugs that are covered and preferred, known as the drug formulary, can change from one year to the next for both Medicare Advantage plans and standalone Part D plans.
AI prior authorization in select states, including N.J.
New Jersey is one of six states where Medicare is testing a new artificial intelligence tool to help approve coverage for certain tests and procedures, a process called prior authorization.
Prior authorization is widely used by private insurers to control costs and safeguard against unnecessary services that may be overprescribed. The tool requires providers to seek approval from the patient’s insurance plan before offering certain services, such as CT scans and X-rays. The practice is often criticized by doctors who say it delays needed care.
Traditional Medicare will use an AI tool to help approve or deny prior authorization requests for select services, including skin and tissue substitutes, electrical nerve stimulator implants, and certain knee procedures.
Emergency care and other treatments that must be done quickly to avoid complications are not affected under the pilot program called the Wasteful and Inappropriate Service Reduction Model.
Results from the six test states will help determine whether the program is more widely used across traditional Medicare in the future. Arizona, Ohio, Oklahoma, Texas, and Washington are the other states where the new technology is being tested.
Medicare Advantage plans already use prior authorization for at least some services, though requirements vary by plan. The practice has been criticized in recent years for delaying needed care.
Beginning in 2026, those plans will be required to respond to prior authorization requests within seven days. The goal is to reduce delays in care being approved and to allow providers to more quickly appeal denials.