Understanding Coordinated Care: How It Improves Health
When it comes to your health, it’s not uncommon to see several doctors, specialists, or therapists over time. But have you ever wondered who’s making sure everyone is on the same page about your care? That’s where understanding coordinated care comes in. This is an approach designed to keep healthcare connected, organized, and focused on the patient as a whole.
What Is Coordinated Care
Coordinated care is a healthcare model that ensures all members of the care team; from primary care providers to specialists, hospitals, and even pharmacists, work together to manage overall health. The goal is simple: to deliver high-quality care that meets healthcare needs while reducing confusion, delays, and unnecessary costs.
Instead of treating each health concern in separately, coordinated care looks at your entire health picture. It’s a team-based, patient-centered approach that emphasizes communication and collaboration across all your healthcare providers.
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How Coordinated Care Works
In a coordinated care system, one provider (often your primary care physician or a dedicated care manager) takes the lead in managing your treatment plan. This person acts as your main point of contact and ensures that:
- Providers share test results and medical records to forma treatment plan
- Treatments don’t overlap or conflict
- You understand your medications and next steps
- Your transition between care settings; such as from hospital to home, goes smoothly
This kind of teamwork helps prevent medical errors, unnecessary repeat tests, and medication mix-ups that can happen when care is fragmented.
Examples
- A person living with diabetes might see a primary care doctor, an endocrinologist, and a nutritionist. In coordinated care, these professionals communicate regularly to align medications, diet recommendations, and follow-up visits.
- After a hospital discharge, a care coordinator might help schedule follow-up appointments, review discharge instructions, and ensure the patient fills their prescriptions; reducing the chance of readmission.
- Many Medicare Advantage and Accountable Care Organizations (ACOs) use coordinated care models to deliver more efficient and effective care for members.
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Why Coordinated Care Matters
Coordinated care isn’t just about organization; it’s about better outcomes. When providers share information and work together, you benefit from:
- Improved overall health
- Fewer hospital visits
- Lower out-of-pocket costs
- Greater satisfaction with your care
Most importantly, it ensures that care reflects your personal goals, preferences, and lifestyle because no one’s health journey looks the same.
Coordinated care is about putting the patient back at the center of the healthcare experience. By connecting the dots between your doctors, specialists, and support services, coordinated care leads to smarter, safer, and more compassionate healthcare.
Whether you’re managing a chronic condition or just want a smoother healthcare experience, coordinated care helps ensure that every part of your health story fits together the way it should.
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Medicare Drug Cost Cap 2026
Beginning in 2025, Medicare introduced one of the most significant changes to prescription coverage in years: a yearly limit on out-of-pocket costs for medications under Medicare Part D. This change continues in 2026, with a slightly higher limit on the Medicare drug cap 2026 designed to help beneficiaries manage rising prescription expenses.
What Is the 2026 Medicare Drug Cap?
In 2026, the Medicare Part D out-of-pocket cap will be $2,100. Once a beneficiary pays $2,100 in out-of-pocket costs for covered prescription drugs in a calendar year, they will owe nothing more for those medications for the rest of the year.
This cap includes deductibles, copays, and coinsurance for covered Part D drugs, but it does not include:
- Monthly Part D premiums
- The cost of drugs covered under Medicare Part B (such as infusions administered in a doctor’s office)
- Medications not on the plan’s formulary
Whether someone has a stand-alone Part D plan or a Medicare Advantage plan with drug coverage, the cap applies to all covered prescriptions.
Why This Change Matters
Before this new system, Medicare beneficiaries had no upper limit on out-of-pocket drug costs. This meant that those with chronic illnesses or expensive specialty medications could spend thousands each year with no relief.
The new $2,100 cap gives beneficiaries greater financial protection and predictability. Once the limit is reached, cost-sharing ends, offering peace of mind for those managing ongoing or high-cost prescriptions.
The increase from $2,000 in 2025 to $2,100 in 2026 accounts for inflation and rising drug prices. This cap is part of the Inflation Reduction Act (IRA), which aims to make medications more affordable and includes additional measures like insulin cost caps and Medicare drug price negotiations.
How the Cap Works
Here’s an example:
Suppose Mary, a Medicare beneficiary, pays copays and coinsurance for her medications throughout 2026. Once her total out-of-pocket spending for covered Part D prescriptions reaches $2,100, she won’t have to pay anything else for those drugs for the rest of the year.
However, it’s important to note that costs for non-covered or Part B drugs won’t count toward the cap. Also, her monthly plan premiums remain separate and will continue.
Watch a YouTube video explaining the drug cap
What Beneficiaries Should Do
Even with this welcome protection, it’s crucial to review your plan each year during the Medicare Annual Enrollment Period (October 15 – December 7). Here’s what to consider:
- Check your plan’s formulary: Make sure all your prescriptions are covered.
- Compare plan costs: Premiums, deductibles, and copays can vary widely between plans.
- Track your spending: Plans will monitor your progress toward the cap, but keeping your own records is wise.
- Explore payment options: The new Medicare Prescription Payment Plan allows beneficiaries to spread out their drug expenses evenly throughout the year instead of paying large costs upfront.
A Step Toward Affordability
The 2026 Medicare drug cost cap is a milestone for millions of Americans who depend on prescription medications. While it doesn’t eliminate all costs, it offers much-needed relief and certainty for those facing high drug expenses.
By understanding how the cap works and reviewing coverage carefully, Medicare beneficiaries can make informed decisions and take full advantage of this new protection.
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Wellcare Spendables Card 2026
The Wellcare Spendables Card continues to be a popular feature of many Wellcare Medicare Advantage (MA) and Dual Eligible Special Needs (D-SNP) plans. The Wellcare Spendables Card 2026 has expanded how and where members can use the card, making it even more valuable for managing everyday health expenses.
What Is the Spendables Card
The Spendables Card is a preloaded debit-style card given to eligible Wellcare members. It includes a monthly or quarterly allowance that can be used for approved health-related purchases. Depending on your plan, the card can pay for:
- Over-the-counter (OTC) health items like pain relievers, cold medicine, or vitamins
- Dental, vision, and hearing costs such as exams, eyeglasses, or dentures
- Healthy groceries and nutritional drinks
- Home safety items like grab bars or bathroom supports
- In some plans, gas, rent, or utility assistance for qualifying members
The allowance amount and eligible categories vary by plan and state, so it’s important to review your plan’s 2026 Summary of Benefits.
What’s New for 2026
1. Expanded coverage: More plans now let members use their Spendables balance on dental, vision, and hearing expenses, not just OTC items.
2. Broader retail network: Members can use their cards at more than 66,000 national retailers, including major pharmacies and grocery stores.
3. Integrated rewards platform: The Spendables Card now connects with the Wellcare Rewards program, so eligible members can manage both benefits through one system.
4. Added flexibility for chronic conditions: Members qualifying under Special Supplemental Benefits for the Chronically Ill (SSBCI) may use their allowance for gas, home safety, rent, pest control, or utility assistance.
Watch a YouTube video about the drug cap
How to Use the Card
After activation (via the member portal, app, or phone), you can use the card like a debit card at approved stores or providers. Common uses include:
- In-store or online OTC purchases at participating retailers
- Paying providers directly for covered dental, vision, or hearing costs
- Purchasing groceries or home items if your plan allows healthy food or safety benefits
If your total purchase exceeds your allowance, you’ll need to pay the difference. Unused balances may roll over month to month but generally expire at year’s end.
Why It Matters
The Spendables Card helps reduce out-of-pocket costs for everyday health needs while giving members flexibility and convenience. It also supports social determinants of health, recognizing that access to food, transportation, and home safety are vital to well-being. For dual-eligible and chronically ill members, the expanded benefits can provide meaningful support beyond medical care.
Key Questions to Ask
Before using your card, confirm:
- How much is my monthly or quarterly allowance?
- What items and services are eligible under my plan?
- Does my plan include healthy food, utilities, or rent benefits?
- Will unused funds roll over?
- Which stores and providers accept the card?
Example in Action
Mary, a Wellcare D-SNP member, receives a $100 monthly allowance. She buys OTC cold medicine and uses the remaining balance toward her dental copay. The next month, she uses part of the card to purchase fresh produce from an approved grocery retailer. Any leftover funds roll into the following month, helping her stretch her allowance through the year.
Final Thoughts
The Wellcare Spendables Card is a strategic benefit that can help Medicare Advantage and D-SNP beneficiaries pay for a wider range of health-supporting purchases in 2026. Going beyond traditional medical care, it reflects a broader view of wellness and takes into account social needs like home safety, food, housing and utilities (for eligible members).
If you or someone you’re helping is enrolling in a Wellcare plan for 2026 or already a member, it’s well worth taking the time to understand exactly how the Spendables card works under their specific plan, what the dollar amount is, what it covers, how to use it; and make a plan to use its allowance wisely.
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Medicare as Primary Insurance
When you turn 65 or qualify for Medicare due to disability, one of the most important things to know is whether Medicare becomes your primary or secondary insurance. Understanding Medicare as primary insurance helps avoid billing issues and unexpected out-of-pocket costs.
What Does “Primary” Mean
The primary payer is the insurance that pays your medical bills first. The secondary payer may cover costs that the primary insurance doesn’t pay; such as deductibles, coinsurance, or copays.
When Medicare is your primary insurance, your healthcare providers bill Medicare first. Once Medicare pays its share, any remaining balance may be sent to your secondary insurance, such as an employer plan or Medigap policy.
When Medicare Is Primary
Medicare typically pays first in these situations:
- You’re retired and not covered by active employer insurance.
Once you stop working and lose active coverage from an employer, Medicare becomes your primary insurance. - You have a small employer plan (fewer than 20 employees).
If you’re still working or covered under a spouse’s small employer plan, Medicare pays first. - You have retiree coverage.
Retiree insurance or COBRA coverage always pays after Medicare. - You have no other insurance.
If Medicare is your only health coverage, it’s automatically primary. - You’re covered by Medicaid.
Medicaid is always the payer of last resort, so Medicare pays first.
Learn about Medicare and employer coverage
When Medicare Is Secondary
In some cases, Medicare may pay after another insurance plan:
- You or your spouse are actively working for an employer with 20 or more employees, and you’re covered under that employer’s health plan.
- You’re receiving workers’ compensation or have a claim covered under no-fault or liability insurance.
- You’re under age 65 and have employer coverage due to disability, and the employer has 100 or more employees.
In these situations, your employer or other insurance must pay first, and Medicare acts as a secondary payer.
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Why It Matters
Knowing when Medicare is primary ensures your medical claims are processed correctly. If you enroll in Medicare but fail to tell your other insurer, or vice versa, you could face denied claims or late enrollment penalties.
Always confirm your coverage status with both Medicare and your employer’s benefits administrator to avoid costly mistakes.
Medicare’s role; whether it’s primary or secondary, depends on your work status, the size of your employer, and any additional coverage you may have.
If you’re nearing retirement or changing jobs, take time to review how your coverage coordinates. Doing so helps ensure smooth billing and gives you peace of mind knowing your healthcare costs are properly covered.
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Understanding Medicare Formulary Exceptions — And How to Get One
When you’re enrolled in a Medicare Part D or Medicare Advantage plan with prescription drug coverage, your plan covers medications according to the plan’s formulary; the list of drugs the plan agrees to cover. What happens if the prescribed medication isn’t on that list, or it’s coverage has restrictions? That’s when understanding Medicare formulary exceptions becomes very important.
A formulary exception is a special request made by a plan enrollee with supporting information from their doctor or directly from their doctor for a plan to cover a drug that’s not included in the plan’s formulary, or to waive certain restrictions, like prior authorization or step therapy.
When You Might Need a Formulary Exception
You might need to request an exception if:
- Your medication isn’t on your plan’s formulary.
- Your plan requires step therapy, meaning you must first try a different (and usually less expensive) drug before the one your doctor prescribed.
- There’s a quantity limit, and your doctor believes you need more than what’s allowed.
- Your plan makes a formulary change mid-year, and the drug you rely on is no longer covered.
If your doctor determines that no covered drug will work as well for your condition, or that other alternatives could cause adverse effects, you can request an exception.
Watch a YouTube video that explains the Drug Cap
How to Request a Formulary Exception
Here’s the process step-by-step:
- Talk to your doctor first. Your prescribing doctor must support your exception request and provide medical justification explaining why the specific drug is necessary.
- Submit the request form. You (or your doctor) will complete your plan’s Coverage Determination Form. Most plans provide this form online or through their customer service department.
- Wait for the plan’s decision.
- The plan must make a decision within 72 hours for standard requests.
- If your doctor believes you need the medication sooner due to your health, you can ask for an expedited (fast-track) review, which requires a decision within 24 hours.
- If denied, you can appeal. You have the right to appeal the decision through multiple levels if necessary. Your doctor can help provide additional medical documentation to strengthen your case.
Tips for a Successful Exception Request
- Provide clear medical justification. The more detailed your doctor’s explanation, the better.
- Submit supporting evidence. Include prior medical history, records of failed alternative treatments, or side effect reports.
- Act early. If you know your plan doesn’t cover a medication, start the exception process before you run out of your current supply.
Formulary exceptions can seem complicated, but they exist to ensure you have access to the medications you truly need. Working closely with your doctor and following your plan’s process carefully can make all the difference.
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If you’re unsure how to begin, contact your plan’s member services department; they can walk you through the steps and provide the necessary forms. Being proactive can help you avoid treatment interruptions and unnecessary stress.
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Medicare Agents as TPMOs: Compliance and Best Practices for Medicare Agents
As a Medicare agent, you are more than just a licensed professional helping beneficiaries find the right coverage; you are officially recognized by CMS as a Third-Party Marketing Organization (TPMO). Understanding Medicare agents as TPMOs is crucial to protecting your business and staying compliant.
What Is a TPMO
CMS defines a TPMO as any organization or individual compensated to perform lead generation, marketing, or enrollment activities for Medicare Advantage (MA) or Part D plans. That means independent agents and brokers fall under the TPMO umbrella whenever they market or sell these plans.
Why It Matters
The TPMO designation exists to ensure transparency, accountability, and consumer protection. CMS tightened these rules in response to misleading advertisements and beneficiary confusion. As a result, every agent who sells MA or Part D plans must meet strict communication and documentation requirements.
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Key Compliance Requirements
Here are the most important rules every TPMO must follow:
- Mandatory Disclaimer: Every piece of marketing material, website, or verbal outreach must include the approved CMS disclaimer: “We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all your options.”
- Call Recording: Any phone call that discusses MA or Part D benefits; even informational calls must be recorded and securely stored for at least 10 years.
- Scope of Appointment (SOA): Always obtain an SOA before discussing plan details. Electronic and paper SOAs are acceptable but must be saved for recordkeeping.
- Avoid Misleading Language: Never imply government affiliation or say you offer “every plan” unless that is true. Be careful with phrasing on social media, websites, and mailers.
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Best Practices for Sales and Marketing
To remain compliant and build trust with clients:
- Lead with education, not sales. Help beneficiaries understand their options before recommending a plan.
- Use CMS-approved materials. Avoid customizing carrier pieces unless approved for agent use.
- Document everything. Keep records of calls, SOAs, and marketing pieces.
- Stay current on CMS updates. Rules can change annually; follow your FMO and carrier training closely.
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Being classified as a TPMO isn’t just a compliance label; it’s a reminder that agents play a critical role in maintaining Medicare integrity. By following CMS rules, staying transparent, and putting client education first, you protect both your license and your reputation in the Medicare marketplace.
Why Medicare Star Ratings Matter – Understanding Their Importance
When comparing Medicare Advantage or Part D prescription drug plans, you’ll see a “star rating” next to each one. These ratings aren’t just numbers; they reflect the overall quality and performance of a plan. Knowing why Medicare star ratings matter can help beneficiaries make a more confident, informed choice.
What Are Medicare Star Ratings
Each year, the Centers for Medicare & Medicaid Services (CMS) rates Medicare Advantage (MA) and Part D plans on a 1-to-5-star scale, with 5 stars being excellent and 1 star being poor.
CMS evaluates plans based on key measures such as:
- Preventive care and managing chronic conditions
- Member satisfaction and customer service
- Medication safety and accuracy of drug pricing
- Handling of complaints and appeals
These ratings help beneficiaries compare plan quality; not just costs.
Why Star Ratings Matter to Beneficiaries
- Quality Over Cost
A low monthly premium might look appealing, but a lower-rated plan could have poorer customer service or fewer care management programs. Star Ratings help you see the bigger picture. - Better Health Outcomes
High-rated plans generally perform better in preventive care, chronic condition management, and prescription safety leading to improved member health. - Special Enrollment Advantage
If a 5-star plan is available in your area, you can use the 5-Star Special Enrollment Period to switch once a year, even outside regular enrollment periods.
Watch a YouTube video on special enrollment periods
Why Star Ratings Matter to Carriers
For insurance carriers, these ratings are more than just feedback — they directly affect their business.
- Financial Rewards: CMS provides quality bonus payments to plans with ratings of 4 stars or higher. These bonuses can help carriers enhance benefits, reduce premiums, and remain competitive.
- Reputation and Market Growth: A higher-rated plan attracts more enrollees. Consumers often view Star Ratings as a trusted indicator of quality and satisfaction.
- Compliance and Accountability: Consistently low ratings can lead to penalties or even removal from the Medicare program. This motivates carriers to continuously improve service, communication, and care coordination.
In short, the Star Rating system drives both accountability and quality improvement for carriers and members alike.
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The Bottom Line
Medicare Star Ratings serve an important purpose for everyone involved. They help beneficiaries choose better plans, encourage carriers to maintain high standards, and ensure that Medicare funds support quality care.
When reviewing plans, remember; the stars tell a story about value, performance, and member experience. Taking time to understand them can make an important difference in satisfaction with healthcare coverage.
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Reasons for MA Plan Cuts – What’s going on
Recently, many insurers are pulling back or dropping Medicare Advantage plans in certain counties. Many Medicare advantage carriers are reducing offerings. This is especially true for PPO plans, which tend to be less restrictive for patients, but also costlier/riskier for insurers. Here’s a breakdown of the reasons for MA plan cuts and why some Medicare Advantage (MA) plans are leaving the market, what it means for enrollees, and how to prepare.
Why Some Medicare Advantage Plans Are Leaving the Market
In 2025 and beyond, several major insurers are scaling back or exiting certain Medicare Advantage (MA) markets. Companies like UnitedHealthcare, Humana, and Aetna are discontinuing specific plans or leaving select counties, affecting hundreds of thousands of beneficiaries. So, what’s driving these exits and what does it mean for Medicare enrollees?
Rising Costs and Slower Reimbursements
The main driver behind these exits is financial pressure. Health care costs; doctor visits, hospital stays, and prescription drugs continue to rise. Meanwhile, the Centers for Medicare & Medicaid Services (CMS) has limited how much funding increases for MA plans each year.
When reimbursement rates don’t keep pace with actual medical spending, insurers are forced to make tough decisions. Some reduce coverage areas; others leave markets entirely. The challenge is even greater in rural counties, where fewer enrollees mean higher per-member costs and less opportunity to spread financial risk.
Increased Regulation and Administrative Burdens
Medicare Advantage plans are subject to strict federal oversight. CMS star ratings, which measure quality and satisfaction, directly affect plan payments and bonuses. Plans with low ratings can face penalties or reduced funding.
New rules around prior authorization, marketing practices, and network adequacy have also added administrative costs. While these policies aim to protect consumers, they make operating certain plans more expensive and complex; especially for smaller carriers.
Shrinking Margins and Risky Plan Types
Preferred Provider Organization (PPO) plans, which allow greater provider flexibility, are especially expensive for insurers to run. In response, many companies are narrowing their focus to Health Maintenance Organization (HMO) plans with tighter networks and lower costs.
However, even with these adjustments, many insurers report that the combination of higher utilization, slower reimbursements, and increased regulation has made some plans unsustainable. As a result, certain counties are seeing fewer plan options for 2026.
Cutting Back on Benefits
To stay competitive and manage costs, insurers are also reducing extra benefits that have become popular selling points for Medicare Advantage plans.
Perks such as dental, vision, hearing, over-the-counter allowances, and fitness memberships are being scaled back or dropped altogether. Some plans have increased copays for specialists, raised out-of-pocket maximums, or restricted drug formularies.
While these changes help insurers control spending, they can leave beneficiaries with fewer incentives to stay on a plan—prompting more people to explore other options like Original Medicare with a Medigap supplement.
What This Means for Beneficiaries
If your Medicare Advantage plan is ending or changing benefits, you’ll receive an Annual Notice of Change (ANOC) this fall. It’s important to read this document carefully. You may find that your premiums, networks, or covered benefits are changing even if your plan remains available.
Here’s what to watch for:
- Fewer local plan options—especially in smaller or rural markets.
- Higher out-of-pocket costs due to benefit reductions or network changes.
- Provider access changes as plans narrow their networks.
- Reduced extra benefits, such as dental, vision, and wellness perks.
Watch a video on discontinued Medicare advantage plan special enrollment periods
If your plan is leaving your area entirely, you’ll qualify for a Special Enrollment Period (SEP) to choose a new plan or return to Original Medicare.
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What You Can Do
- Review your ANOC early to understand all upcoming changes.
- Compare new plans on Medicare.gov or with a licensed agent to see what’s available in your ZIP code.
- Look beyond the premium. Consider total out-of-pocket costs, copays, and your provider network.
- Verify your prescriptions. Ensure your medications are still covered under the plan’s formulary.
- Explore Medigap and Part D options if you want more stability or broader provider access.
The Bottom Line
Medicare Advantage remains a strong and growing program, but rising costs and tighter reimbursement rules are forcing insurers to reassess their participation. Many are choosing to leave certain counties or reduce extra benefits to stay financially viable.
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For beneficiaries, staying informed is key. Review your plan each year, compare options carefully, and don’t assume your current benefits will stay the same. A little preparation can help avoid surprises and ensure you continue to get the coverage and care you need.
Medicare Sales Compliance Rules – What Not to Say During a Medicare Sale
When you with meet with Medicare beneficiaries, the words you choose matter. CMS has strict marketing guidelines, and violating them can lead to serious issues, this includes fines or even loss of contracts. To protect your clients and your business; we will go over some Medicare Sales Compliance Rules regarding things Medicare agents cannot say or do during a sales appointment.
“We offer every Medicare plan available”
This statement is misleading. Not all plans contract with independent agents, and no agent can truly offer every plan. You may represent several excellent plans, but accuracy is essential. Always choose wording carefully on printed materials and in conversations.
Remember: CMS requires TPMOs (Third-Party Marketing Organizations) to include a disclaimer on all marketing materials, communications, and even phone calls with prospective clients.
“This plan is free”
CMS marketing guidelines prohibit agents from using the word free to describe any plan.
- A $0 premium does not mean the plan has no costs.
- Enrollees are still responsible for deductibles, co-pays, and coinsurance.
- Network restrictions often apply.
The word free is misleading and should never be used when describing Medicare plans, premiums, deductibles, or cost-sharing.
Watch a YouTube video on CMS final rule 2026
“This plan covers everything you need”
There is no Medicare plan that covers all of someone’s health needs. The agent’s role is to help clients compare options and choose what best fits their personal situation. Present the pros and cons, but never promise that a plan will meet 100% of their needs.
“This is the best plan”
Superlatives like “best” are not allowed unless supported by verifiable, CMS-approved data. What’s best for one client may not be best for another. Always focus on what meets that client’s needs, not a blanket claim.
“Medicare approves this plan’s benefits”
You cannot say or imply that Medicare endorses, approves, or recommends a plan. While Medicare Advantage and Part D plans must meet CMS standards, they are offered by private companies; not by Medicare itself.
Talking about non-Medicare products during an SOA
Stick to the Scope of Appointment (SOA). If the SOA only covers Medicare Advantage, you cannot bring up Medigap, Part D, or life insurance. If a client asks about other products, suggest scheduling another appointment.
Asking for friends’ or family contact info
You cannot request phone numbers or addresses of potential referrals. What you can do is hand clients extra business cards so they can share your information with others who may be interested.
Offering gifts or money for enrollment
Agents cannot provide financial incentives or high-value gifts in exchange for signing up. CMS allows small promotional items (worth $15 or less per item, up to $75 per year per person).
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Scare tactics or misinformation
Do not tell clients their current coverage will change just to push a new plan. You may compare benefits factually but avoid scare tactics. Clients must feel educated, not pressured.
Medicare compliance is about accuracy, transparency, and respect. Stick to CMS-approved language, avoid misleading claims, and always tailor your advice to the individual client. Doing so not only keeps you compliant; it builds lasting trust.
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Medicare Part B Costs 2026
Medicare Part B helps cover medically necessary outpatient services, doctor visits, preventive services, medical equipment, and more. Because like many aspects of health care, its costs change annually, We will discuss the Medicare Part B costs 2026. beneficiaries and future enrollees need to know what’s ahead.
Below, we explore the projected premiums, deductibles, income-based surcharges (IRMAA), and strategies for planning.
What’s Covered by Part B & Basic Costs
Before diving into 2026, here’s a quick recap of how Part B costs typically work:
- You pay a monthly premium for Part B (unless you qualify for assistance).
- You also pay a yearly deductible before Medicare pays (for most services).
- After meeting the deductible, Medicare generally covers 80% of approved costs for covered outpatient services; you’re responsible for the remaining 20% coinsurance (unless another plan helps).
- If your income is above certain thresholds, you may pay an extra surcharge (IRMAA).
- Costs can vary based on where you live, your coverage options (like Medigap or Medicare Advantage), and your income.
These rules remain consistent, even as dollar amounts shift over time.
Projected Part B Premium in 2026
According to the Medicare Trustees’ projections and other financial analysts, the standard Part B monthly premium is expected to rise from $185 in 2025 to $206.50 in 2026 an increase of $21.50, or roughly 11.6%.
That jump would be the largest single-year dollar increase in recent years.
It’s crucial to note: this “standard” premium applies to beneficiaries without additional income-based surcharges (i.e. those whose incomes fall under the IRMAA thresholds). Those with higher incomes will pay more.
Expected Part B Deductible in 2026
While the exact deductible for 2026 will not be finalized until closer to year-end 2025, current projections suggest it may rise from $257 in 2025 to $288 in 2026.
That would be a roughly 12% increase in the amount beneficiaries pay out of pocket before Medicare starts covering your outpatient services.
Some Medigap (supplemental) plans cover the deductible; others require you to pay it yourself, so an increase could matter more to those on certain Medigap plans.
Income-Related Monthly Adjustment Amount (IRMAA) for 2026
One of the most significant cost levers in Medicare is the IRMAA surcharge: higher-income beneficiaries pay extra on top of the base premium. Here’s what’s projected for 2026:
- The 2026 IRMAA brackets and surcharge amounts are based on modified adjusted gross income (MAGI) from your 2024 tax return.
- The income thresholds (for moving among surcharge tiers) are expected to be indexed upward (adjusted for inflation) for 2026.
- The average surcharge increases for Part B are projected to be modest; around 1.04%.
Because of IRMAA, two people in the same city with different incomes might pay very different Part B amounts.
Why Are Costs Rising
Several forces contribute to rising Medicare Part B costs:
- Medical inflation and utilization – Outpatient services, physician-administered drugs, diagnostics, and usage of health services often rise faster than general inflation.
- Aging population / higher demand – As more retirees enter Medicare and health care needs grow, the burden on the system increases.
- Cost shifting – Higher-income beneficiaries absorb more of the cost via IRMAA, but base premiums still have to cover a portion of system-wide costs.
- Policy adjustments & fund dynamics – Adjustments to how much premiums are allowed to cover, budget pressures, and funding decisions all play a role.
- Legislative changes – New laws affecting drug pricing, Medicare rules, and benefit design indirectly affect Part B costs over time.
Watch a YouTube video on the discontinued Medicare advantage plan special enrollment period
What It Means for Beneficiaries
- Budget impact: That extra $21.50 per month may absorb a significant chunk of any Social Security cost-of-living adjustment (COLA). Indeed, projections show much of retirees’ COLA gains may be eaten by higher health costs.
- Planning ahead: If your income is near an IRMAA threshold, small changes (e.g. capital gains, extra work income, withdrawals) could push you into a higher bracket.
- Review your coverage: Supplemental (Medigap) or Medicare Advantage plans may mitigate some out-of-pocket costs. If your Medigap plan covers the Part B deductible, the increase matters more.
- Appeal or exemption: If your income decreases substantially due to life events (e.g. retirement, widowhood), you may be able to appeal IRMAA adjustments.
- Stay informed: Final Medicare pricing is announced in late 2025. Propose your budget accordingly but expect adjustments.
Tips to Manage the Cost Increase
- Estimate your 2024 MAGI now — knowing whether you might cross an IRMAA threshold will help with tax planning or withdrawals.
- Delay or stagger income where possible — if legally and financially feasible, deferring income from 2024 may help you stay lower in the IRMAA tiers.
- Choose the right supplemental plan — some Medigap policies cover the Part B deductible or reduce your coinsurance burden.
- Stay within the initial enrollment windows — avoid late enrollment penalties, which add to cost burdens.
- Appeal IRMAA where applicable — if you experience life-changing events, you may qualify for exceptions.
- Watch your investments and gains — high capital gains or distributions in 2024 could unexpectedly push your MAGI upward.
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Bottom Line
Based on current projections:
- The standard Part B premium in 2026 may reach $206.50 per month, up from $185 in 2025.
- The deductible is expected to rise to about $288.
- Income-based surcharges (IRMAA) may add considerably more for higher earners.
- The increase is sizable and could erode a portion of any Social Security increase.
- Planning ahead; particularly regarding your 2024 income, can help reduce the surprise.
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Which Vaccines Does Medicare Cover
Vaccinations are an important part of preventive healthcare, especially for older adults who may be at higher risk of serious illness. Fortunately, Medicare provides coverage for many common vaccines, but which vaccines does Medicare cover? Additionally, knowing which part of Medicare covers what can help beneficiaries avoid surprise costs.
Vaccines Covered by Medicare Part B
Medicare Part B covers certain vaccines that are considered medically necessary for disease prevention. These include:
- Flu shot (Influenza vaccine): Covered once per flu season, and sometimes more if medically necessary.
- Pneumococcal vaccine: Helps prevent pneumonia and other infections. Medicare covers two different pneumococcal shots at no cost when given at least one year apart.
- Hepatitis B vaccine: Covered for beneficiaries at medium or high risk (such as those with diabetes, liver disease, or certain occupational exposures).
- Vaccines needed due to injury or exposure: For example, if you’re exposed to rabies or step on a rusty nail and need a tetanus shot, Medicare Part B covers it.
There’s no deductible or copayment for these vaccines if you receive them from a provider who accepts Medicare assignment.
Vaccines Covered by Medicare Part D
Medicare Part D (prescription drug coverage) handles most other commercially available vaccines that are not covered by Part B. This includes:
- Shingles (Herpes Zoster) vaccine
- Tetanus, Diphtheria, and Pertussis (Tdap) vaccine when not related to an injury
- RSV (Respiratory Syncytial Virus) vaccine for older adults
- Travel vaccines, such as those for hepatitis A or typhoid, depending on your plan
Part D plans must cover all vaccines recommended by the Centers for Disease Control and Prevention (CDC) that aren’t already covered by Part B. Since 2023, beneficiaries pay no out-of-pocket costs for these recommended vaccines under Part D.
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Why Staying Up to Date Matters
Getting the right vaccines can help prevent hospitalizations and serious illness. With Medicare’s expanded coverage, beneficiaries can stay current on vaccinations at little to no cost. It’s always best to check with your provider or Part D plan to confirm coverage before receiving any vaccine
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Medicare makes it easier than ever to stay protected. Part B covers flu, pneumonia, Hepatitis B (for those at risk), and vaccines needed due to injury, while Part D covers all other recommended vaccines; often at no cost.
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Common Medicare Beneficiary Mistakes
Medicare can be confusing, especially with its many rules and enrollment periods. Unfortunately, even small mistakes can lead to coverage gaps or lifetime penalties. Here are some of the most common Medicare beneficiary mistakes and missteps to avoid.
Missing Your Initial Enrollment Period
Your Initial Enrollment Period (IEP) is your first chance to enroll in Medicare. It starts three months before your 65th birthday, includes your birthday month, and ends three months after. Waiting too long to sign up can delay your coverage and lead to permanent late enrollment penalties — especially if you don’t have other creditable insurance.
Watch a YouTube video on Medicare enrollment periods
Assuming COBRA or Retiree Coverage Lets You Delay Medicare
If you have COBRA or retiree insurance, don’t assume it allows you to postpone Medicare. COBRA is not creditable coverage for delaying Part B or Part D. Failing to enroll when first eligible can leave you uninsured and subject to lifetime penalties once you do sign up.
Not Enrolling While Working for a Small Employer
If you’re still working and your company has 20 or fewer employees, Medicare becomes your primary insurance, not your employer plan. Failing to enroll in Medicare on time could mean denied claims and unexpected bills.
Ignoring the Need for a Part D Drug Plan
Even if you don’t take prescriptions, you should enroll in a Part D plan when first eligible. Without it, you’ll face a permanent late enrollment penalty once you do sign up, and you’ll have to wait until the next enrollment period for your coverage to start. Many beneficiaries choose an inexpensive plan simply to avoid future penalties.
Confusing Medigap Enrollment Rules
Unlike Medicare Advantage or Part D, Medigap doesn’t have an annual election period. Your one-time Medigap Open Enrollment Period begins when you enroll in Part B. During these six months, you can get a Medigap plan with no health questions — miss it, and medical underwriting could apply later.
Paying the Part B Deductible Too Soon
Some providers mistakenly request the Part B deductible before Medicare processes your claim. Always wait until Medicare applies the deductible to the correct bill to avoid confusion or overpayment.
Bottom Line
Understanding Medicare’s timelines and coverage rules can save you from penalties, gaps and unnecessary stress. Taking the time to review coverage options and asking your agent questions before you enroll helps you get the most out of your benefits.