2026 Guide to Medicare Plans

What’s New in 2026?

The Centers for Medicare & Medicaid Services (CMS) implemented key Medicare updates in 2026. Here’s what you need to know:

Automatic Enrollment in Prescription Payment Plan

If you use the Medicare Prescription Payment Plan to spread drug costs over the year, you’ll now be automatically re-enrolled each year starting in 2026. You can opt out if needed.

Part D Out-of-Pocket Cap Set at $2,100

Your total annual out-of-pocket spending on prescription drugs under Medicare Part D will be capped at $2,100.

Changes to Medicare Advantage Chronic Illness Benefits

Medicare Advantage plans with Special Supplemental Benefits for the Chronically Ill (SSBCI) may not cover certain non-health-related extras previously provided.

$35 Monthly Insulin Cap Continues

Insulin costs stay capped at $35 per month with no deductible. Pricing will use the most favorable of several formulas to keep costs low.

Free ACIP-Recommended Vaccines Remain

Adult vaccines recommended by the Advisory Committee on Immunization Practices (ACIP) will remain free under Part D, with no copay or deductible. However, it is also recommended that beneficiaries check with the pharmacy or doctor’s office to confirm Medicare will cover the expense for immunization boosters at 100% for the 2026 plan year. 

What’s Original Medicare?

Original Medicare is a federal health insurance program designed for:

• Individuals aged 65 or older
• People under 65 with certain disabilities
• Individuals with End Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS)

Original Medicare Parts Overview

Original Medicare includes:

 Part A (Hospital Insurance), which covers:

• Inpatient care in hospitals
• Skilled nursing facility care
• Hospice care
• Home health care

 Part B (Medical Insurance): which covers:

• Services from doctors and other healthcare providers
• Outpatient care
• Home health care
•  Durable medical equipment (e.g., wheelchairs, walkers)
•  Preventive services (e.g., screenings, vaccines)

Additional Medicare Plan Coverage Options From Independent Companies

Part C (Medicare Advantage Plans) is provided by private companies, Part A, Part B, and may also include Part D prescription drug coverage. Medicare Advantage plans may offer additional benefits but might have network restrictions and require prior approval for some services.

Medicare Part D (Drug Coverage): Also provided by independent insurance companies,  and is available through standalone plans or as part of Medicare Advantage Prescription Drug Plans.

Original Medicare vs. Medicare Advantage

•  Original Medicare: Offers flexibility to use any Medicare-approved doctor or hospital. You may purchase Medicare Supplement Insurance (also known as Medigap in many states) to cover additional out-of-pocket costs.
• Medicare Advantage: Provides a managed care alternative from an independent insurer that includes Medicare Part A and Part B, and may include additional benefits but may limit your provider choices and require pre-authorization for certain services.

What’s Medicaid?

Medicaid is a joint federal and state program that assists with medical costs for individuals with limited income and resources. It covers services not typically included in Original Medicare, such as nursing home care and personal care services. Eligibility varies by state.

Special Dual Eligibility

Original Medicare and Medicaid: If eligible for both, Original Medicare generally pays first for covered services, followed by Medicaid. Medicaid may cover some prescription drugs not included under Original Medicare.

For more information:

•  Visit Medicare.gov for details on plans, costs, and providers.
•  Call 1800MEDICARE (18006334227) for personalized help.
•  Contact your local State Health Insurance Assistance Program (SHIP) for free, local counseling.
• Government Resources: Medicare.gov Guide to Medicaid and Medicare

Signing Up For Original Medicare

Do You Need to Apply for Original Medicare?

• Automatic Enrollment: If you’re 65 and already receiving Social Security or Railroad Retirement benefits, you may be automatically enrolled in Original Medicare Part A and B.
• Manual Application: If you’re not receiving benefits and lack employer health coverage, you need to apply as you approach age 65.

How to Apply for Original Medicare:

Apply via the My Social Security account. Verify your identity with a:

• Social Security number
• Valid U.S. mailing address
• Email address
• Date and place of birth
• Permanent Resident Card (if applicable)
• W2 and tax forms
• Medicaid number (if applicable)
• Group health insurance details (if applicable)

After applying, keep your confirmation number to check your application status.

When to Enroll in a Medicare Plan:

Timing your enrollment is just as important as choosing the right plan.

Enrollment Windows:

• Initial Enrollment Period (IEP): 7-month period around your 65th birthday.
  
• Annual Enrollment Period (AEP): October 15 to December 7 each year.
  
• Medicare Advantage Open Enrollment: January 1 to March 31 (for current MA enrollees only).
  
• Special Enrollment Periods (SEPs): For life events like moving or losing other coverage.
  

Original Medicare vs. ACA Health Insurance Marketplace

If you have Affordable Care Act (ACA) Marketplace coverage, you should generally sign up for Original Medicare when you are first eligible to avoid coverage delays and potential penalties.

The ACA or Obamacare was introduced in 2008. It created the Health Insurance Marketplace to simplify coverage access and provide financial assistance. State-based marketplaces for ACA enrollment are available in certain states.

ACA plans offer a variety of affordable options for millions, including those self-employed or between jobs.

Key Features:

•  Marketplace: Enroll via HealthCare.gov or state-based platforms to compare insurance options.
•  Pre-Existing Conditions: Coverage cannot be denied due to pre-existing conditions.
•  Subsidies: Eligible individuals and families may receive tax credits to lower monthly premiums. Check your estimated eligibility using our ACA subsidy calculator via Healthcare Insider.

You can keep your ACA Marketplace plan until Original Medicare starts. However, once you qualify for premium-free Part A or already have Part A, you may need to end your ACA coverage to avoid paying back subsidies.

Original Medicare Resources

• Read your “Medicare & You” handbook
• Contact your State Health Insurance Assistance Program (SHIP)

Understanding Medicare Supplement Insurance (also known as Medigap)

Medicare Supplement Insurance, also known as Medigap, is additional insurance offered by independent companies designed to help cover out-of-pocket costs associated with Original Medicare. Here’s what you need to know:

 Coverage: Medicare Supplement plans may help with costs not covered by Original Medicare, such as:

•  Copayments
•  Coinsurance
•   Deductibles
•   Foreign travel emergency care (not covered by Original Medicare)

Eligibility

To purchase a Medicare Supplement policy, you must:

•  Have Original Medicare (Part A and Part B)
•  Not be enrolled in Medicare Advantage Plans, Medicaid, or other types of health coverage like TRICARE or employer health plans

 Policy Features:

• Standardization: Medicare Supplement Insurance policies are standardized in most states and identified by letters (e.g., Plan G, Plan L, Plan N, etc.). All policies of the same letter provide the same basic benefits, regardless of the insurer.
•  Availability: There are ten supplemental Medicare Supplement plans available in most states, each with varying levels of coverage. Note that Plan C and Plan F are not available to new Original Medicare enrollees after January 1, 2020, due to changes in coverage for the Part B deductible.
• Coverage Differences: Plans D and G offer different benefits depending on when they were purchased, and plans E, H, I, and J are no longer sold but can be kept if already held.

Buying Tips:

The optimal time to purchase a Medicare Supplement (Medigap) policy is during your Initial Open Enrollment Period, which starts the first month you are 65 and enrolled in Original Medicare Part B.

During this time, you can choose any Medicare Supplement policy without medical underwriting.

 Plan Pricing:

 Medigap policies are priced in different ways—community-rated, issue age-rated, or attained age-rated—which can impact your premium costs.

What’s Not Covered

Medicare Supplement plans do not cover:

• Long-term care
• Vision and dental care
• Hearing aids and eyeglasses
• Private duty nursing

Understanding Original Medicare Coverage and Costs

Navigating Original Medicare can be complex, but understanding what’s covered and how much you might pay is essential for managing your healthcare expenses. Original Medicare generally covers services and items deemed “medically necessary” to treat diseases or conditions. Here’s a concise guide to help you understand what Original Medicare covers and your potential costs:

 What Original Medicare Covers:

• Medically Necessary services include hospital stays, surgeries, lab tests, and doctor visits.
•  Medically Necessary items include durable medical equipment, for example,  wheelchairs and walkers.

 Factors Affecting Coverage:

• Federal laws define Original Medicare benefits, while state laws may dictate what services providers can offer.
• National Coverage Determinations: Original Medicare establishes national coverage for specific items and services.
• Specific Conditions: Some services or items may only be covered in certain settings or if specific conditions are met. For instance, organ transplants must be done in approved hospitals.

 Finding Coverage Information:

• Discuss with your healthcare provider about the necessity of services or items and whether Original Medicare will cover them.

Estimating Surgery Costs:

• Procedure Price Lookup: Use this Medicare.gov tool to estimate costs.
•  Consult Healthcare Providers: Ask about the costs of the procedure and any additional care needed.
•  Check Your Original Medicare Summary Notice: Review whether you’ve met Part A or B deductibles and potential copayments.
• Verify with Other Insurance: If you have additional insurance like Medicare Supplement Insurance or Medicaid, check their coverage.

Reducing Your Costs:

Ask About Assignment: Ensure your provider accepts assignment to cover the Original Medicare-approved amount.

 Explore Assistance Programs: Look into programs for financial assistance if you have limited income. 

By staying informed and proactive, you can better manage your Original Medicare coverage and associated costs. For further information, always refer to official Medicare resources or contact Medicare.gov directly.              

Telehealth Coverage Adjustments

Through September 30, 2025, beneficiaries can access telehealth services at any location in the U.S., including their homes. Starting October 1, 2025, you must be in an office or medical facility located in a rural area (in the U.S.) for most telehealth services. If you aren’t in a rural health care setting, you can still get certain Medicare telehealth services on or after October 1, including:

• Monthly End-Stage Renal Disease (ESRD) visits for home dialysis
• Services for diagnosis, evaluation, or treatment of symptoms of an acute stroke, wherever you are, including in a mobile stroke unit
• Services for the diagnosis, evaluation, or treatment of a mental and/or behavioral health disorder (including a substance use disorder) in your home

Chronic Pain Management

 Medicare will now cover monthly services for treating chronic pain if you have been suffering from it for more than three months.

Enhanced Mental Healthcare

Coverage has expanded to include intensive outpatient program services provided by hospitals, community mental health centers, and other facilities.

More Enrollment Opportunities

You can qualify for Medicare plans during a special enrollment period if you are turning 65, new to Medicare, moving, or losing coverage. During the Annual Enrollment Period, a beneficiary can join, switch, or drop their Medicare plan.

Ongoing COVID19 Support

Original Medicare continues to cover the COVID-19 vaccine along with various tests and treatments to safeguard your health.

Extra Help Program Changes

The Extra Help program has been expanded to provide greater coverage for individuals with limited resources and income.

For detailed information, refer to the specific pages mentioned in the 2025 Medicare & You handbook.

Medicare Resources

• For more information on Medicare Supplement, visit the Medicare.gov “Medicare & You’ Handbook.
• Need Local Help With Medicare? State Health Insurance Assistance Programs offer personalized, one-on-one insurance counseling and Medicare assistance.

Preventive Services Covered By Original Medicare

Original Medicare provides extensive coverage for preventive services designed to help detect and address health issues before they become serious problems. Here’s an overview of the key preventive services covered by Original Medicare, detailing what’s included, how often they’re covered, and potential costs.

Abdominal Aortic Aneurysm Screening

Coverage: Original Medicare covers an abdominal aortic aneurysm screening ultrasound once in your lifetime if you’re at risk and have a referral from your doctor.

Who’s at Risk:

•  Family history of abdominal aortic aneurysms.
•  Men aged 65–75 who have smoked at least 100 cigarettes in their lifetime.

Costs: Free if your provider accepts assignment.

Alcohol Misuse Screening and Counseling

Coverage: Original Medicare covers one alcohol misuse screening per year and up to four brief counseling sessions if misuse is identified.

Costs: No charge if your provider accepts assignment. Counseling must occur in a primary care setting.

Bone Mass Measurements

Coverage: Original Medicare covers bone mass measurements if you’re at risk for osteoporosis, based on medical history or ongoing treatments.

Frequency: Once every 24 months, or more often if medically necessary.

Costs: Free if your provider accepts assignment.

Cardiovascular Behavioral Therapy

Coverage: Annual cardiovascular behavioral therapy visits to discuss diet, exercise, and aspirin use.

Costs: Free if your provider accepts assignment.

Risk Factors:

1.  High blood pressure
2.  Unhealthy cholesterol levels
3.  Diabetes
4.  Overweight
5.  Tobacco and/or alcohol use

Cervical and Vaginal Cancer Screenings

Coverage: Original Medicare covers Pap tests and pelvic exams for cervical and vaginal cancer screenings, including a clinical breast exam.

Frequency:

• Pap tests and pelvic exams: Once every 24 months (or annually if high risk).
• HPV tests: Once every 5 years for women aged 30-65.

Costs: Free if your provider accepts assignment.

Risk Factors for Cervical Cancer:

• History of sexually transmitted diseases
• Early sexual activity
• Multiple sexual partners
• Abnormal Pap test history

Colorectal Cancer Screenings

Coverage: Original Medicare covers various screenings, including colonoscopies, fecal occult blood tests, flexible sigmoidoscopies, and more.

Frequency:

• Colonoscopy: Every 120 months (or 24 months if at high risk).
• Fecal occult blood test: Annually.
• Flexible sigmoidoscopy: Every 48 months (or 120 months after a colonoscopy if not high risk).

Costs: Free for most tests if your provider accepts assignment. Additional costs apply if polyps are removed during a colonoscopy.

Risk Factors for Colorectal Cancer:

• Age
• Personal or family history of colorectal cancer or polyps
• Inflammatory bowel disease

Depression Screening

Coverage: Original Medicare covers one depression screening per year in a primary care setting.

Costs: Free if your provider accepts assignment.

Diabetes Screenings and Self-Management Training

Coverage: Original Medicare covers up to two diabetes screenings per year and outpatient self-management training for diagnosed diabetes.

Costs: Free for screenings if your provider accepts assignment. Self-management training may involve a 20% copayment after the Part B deductible.

Risk Factors for Diabetes:

• High blood pressure
• Obesity
• Family history of diabetes

Flu Shots

Coverage: Original Medicare covers the seasonal flu shot once each flu season.

Costs: Free if your provider accepts assignment.

Glaucoma Screenings

Coverage: Original Medicare covers glaucoma screenings once every 12 months if you’re at high risk.

Costs: 20% of the Original Medicare-approved amount after the Part B deductible, with possible additional copayments in hospital outpatient settings.

Risk Factors for Glaucoma:

• Diabetes
• Family history of glaucoma
• Certain ethnic backgrounds

Hepatitis B Shots and Screenings

Coverage: Original Medicare covers Hepatitis B shots and screenings for those at high risk or pregnant.

Costs: Free if your provider accepts assignment.

Risk Factors for Hepatitis B:

• Diabetes
• Certain occupations and conditions

 Hepatitis C and HIV Screenings

Coverage: Original Medicare covers Hepatitis C screenings for certain risk groups and HIV screenings for individuals.

Costs: Free if your provider accepts assignment.

 Lung Cancer Screenings

Coverage: Original Medicare covers annual low-dose CT scans for lung cancer screening if you meet specific criteria, including smoking history.

Costs: Free if your provider accepts assignment.

Risk Factors for Lung Cancer:

• Smoking history
• Exposure to secondhand smoke or cancer-causing agents

Mammograms (Breast Cancer Screenings)

Coverage: Original Medicare covers annual screening mammograms for women 40 and older, diagnostic mammograms as needed, and one baseline mammogram for women aged 35-39.

Costs: Free for screening and baseline mammograms; 20% of the Original Medicare-approved amount for diagnostic mammograms after meeting the Part B deductible.

Medicare Diabetes Prevention Program

Coverage: Original Medicare covers this program for those at risk of type 2 diabetes, including core sessions and follow-up support.

Costs: Free if you qualify.

Obesity Behavioral Therapy

Coverage: Original Medicare covers screenings and counseling for obesity with a BMI of 30 or more.

Costs: Free if your provider accepts assignment.

Pneumococcal Shots

Coverage: Original Medicare covers pneumococcal vaccines to protect against pneumonia.

Costs: Free if your provider accepts assignment.

Prostate Cancer Screenings

Coverage: Original Medicare covers PSA blood tests and digital rectal exams for men over 50.

Costs:

• PSA test: Free.
• Digital rectal exam: 20% of the Original Medicare-approved amount after the Part B deductible.

Sexually Transmitted Infection Screenings and Counseling

Coverage: Original Medicare covers STI screenings and counseling if you’re pregnant or at increased risk.

Costs: Free if your provider accepts assignment.

“Welcome to Original Medicare” Preventive Visit

Coverage: Original Medicare covers this one-time visit within the first 12 months of having Part B.

What’s Included:

• Medical history review
• Preventive services information
• BMI calculation
• Vision test
• Depression risk assessment

Costs: Free if your provider accepts assignment.