Share With Your Clients
The last few years have shown a trend of Medicare beneficiaries choosing to enroll in Medicare Advantage plan over Original Medicare. They like the convenience of an all in one plan, lower out of pocket costs and the supplemental benefits offered by MA plans. But 2026 may be the year that starts to reverse this trend.
Many MA enrollees have been notified their plan is no longer being offered in 2026. They may find there are fewer MA plans available in their area and these plans are not as enticing as they have been in the past. As insurers grapple with difficult financial decisions, your clients may be faced with any or all of the following for 2026:
- Higher out-of-pocket costs. Monthly premiums have increased with fewer $0-premium plans on the market. Many plans have added medical and Rx deductibles and have increased copays and coinsurances.
- Changes to provider networks. They may find their preferred doctors or hospitals are no longer in the plan’s network.
- Changes to drug formularies. They may find their drugs cost more or are no longer on the plan’s formulary.
- Fewer supplemental benefits. Plans may no longer offer certain extras, such as over-the-counter allowances, home delivered meals or transportation. Coverage limits may be reduced for dental, vision or hearing benefits.
These changes may have some of your clients considering whether they should switch to Original Medicare. Many Medicare beneficiaries have only ever been enrolled in an Advantage plan, so they may be completely unaware of the differences. You will play an important role in educating them and helping them determine whether the switch is right for them.
Benefits of Original Medicare
- No Networks. Original Medicare has no provider networks. Coverage is good with any medical provider that accepts Medicare assignment, meaning they accept the Medicare approved amount as payment. Since there are fewer PPO plans on the market for 2026, Original Medicare can be a good option for clients who want to travel or seek care outside of an insurer’s network. It might be the only option for MA enrollees who want to ensure access to specific providers if their plan no longer includes them in their network.
- Fewer Prior Authorizations. MA plans use prior authorizations to control costs by ensuring certain procedures are medically necessary. But for some, the authorization process can slow down access to care or even lead to a denial of coverage. While Original Medicare is piloting a prior authorization program in 2026 for certain services in six states, including Texas, most services do not require prior authorization.
Understanding Out of Pocket Costs
The deductibles, copays and coinsurances associated with Part A and B may be completely new to those with MA plans. They are also accustomed to an out-of-pocket maximum with their current coverage. You will need to help your clients understand these costs and how a Medigap plan can help cover these expenses.
Enrolling in a Medigap Plan
In most states, those who did not enroll in a Medigap plan during their Initial Enrollment Period are required to undergo medical underwriting. They could be denied coverage based on pre-existing conditions.
However, these rules are different for those who have had their Medicare Advantage plan discontinued. They are entitled to a Special Enrollment Period that allows them to switch back to Original Medicare and enroll in a Medigap plan without undergoing medical underwriting. They have 63 days from the date their Medicare Advantage plan ends to apply for a Medigap policy. They cannot be denied coverage or charged more for a plan.
Choosing the Right Plan
Since Medigap plans are sold by private insurers, the costs can vary but the benefits are standardized, meaning the policies with the same letter names offer the same benefits no matter who the insurer is. Costs can also vary based on age, sex, and smoking history. There are 10 different plans each offering different benefits. Not all plans are available in all areas, and some plans are no longer available for those who turned 65 after January 1, 2020. You will need to work with each individual client to determine which plan offers the benefits that best fit their needs and budget
Part D Coverage
Your clients with MA plans may be used to having their Part D coverage as part of their plan. If they want to switch to Original Medicare you will need to help them find a stand-alone Part D plan. This does give them a chance to shop different insurers to find a formulary that offers the medications they need at price they can afford.
What Is Not Covered
In addition to Part D coverage, Medigap plans also do not offer coverage for vision care, dental care and hearing aids. It does not cover any of the extra benefits offered by Medicare Advantage plans, such as gym benefits.
This will be a difficult year for some of your clients who may have trouble finding the coverage they want at a price they can afford. Make your clients aware of federal programs such as Medicare Savings Programs and Extra Help, or state programs such as Medicaid and Texas Rx Assistance Programs that can help them with their out-of-pocket expenses.
Your clients will appreciate having you by their side as they navigate these changes and make the best possible coverage decisions for 2026.