Navigating Medicare can feel overwhelming—especially when the rules seem to change every year. As caregivers and family advocates, staying informed is key to protecting your loved one’s health and finances. With several important Medicare updates rolling out for 2026, it’s more important than ever to review your options and avoid costly surprises.
1. Plan Availability & Regional Changes
- Plan Discontinuations: Some Medicare Advantage (Part C) and standalone Part D prescription drug plans are being discontinued in select counties across Wisconsin, Southeast Minnesota, and Northwest Iowa. If your current plan is affected, you should have received a notification—but don’t assume you’re in the clear. Double-check your coverage to ensure you’re not left without essential benefits.
- New Plan Entrants: Good news for some regions! New Medicare Advantage plans are launching in parts of Wisconsin and Lake County, IL, with expanded benefits such as transportation, meal delivery, and more. These options may better fit your loved one’s needs—especially if extra support services are important.
- Network Changes: Even if your plan continues, provider networks are shifting. Some popular Medicare plans have updated their lists of covered doctors and hospitals for 2026. This means your preferred physician or preferred hospital could be “out-of-network” next year, potentially leading to higher costs or the need to switch providers.
- Contract Changes: Hospitals and Clinics, independent provider clinics, etc. enter into a contract with insurance companies to accept payment. Some areas of the country are not renewing some insurance plans that may put you at risk. During the annual open enrollment, check-in with your clinic and hospital system (they may send you to the billing department) to make sure your Medicare insurance will still be an option for services at your doctor, clinic, and hospital.
Sintra Image: aging couple meeting with Medicare Advisor
2. Government Updates & Policy Changes
Medicare policy is always evolving. For 2026, there are changes in how some prescription drugs are covered and new rules about how plans communicate changes to members. It’s essential to read all plan notices carefully and reach out for help if anything is unclear. The maximum drug payment did increase to 2100.00 for 2026, up 100.00 from last year.
- Insulin cost cap continues: Most Medicare drug plans will continue to cap insulin costs at $35/month in 2025.
- Vaccines: More vaccines (including RSV) are now covered at no out-of-pocket cost.
- Mental health coverage: Expanded access to telehealth mental health services, especially in rural areas.
- Part B Premiums: Expect a slight increase in monthly premiums for most enrollees.
- Drug price negotiations: The first round of government-negotiated drug prices will begin to affect select high-cost prescriptions in 2025.
- Observation status: New rules require hospitals to notify patients if they are under “observation” instead of admitted, which can impact post-hospital skilled nursing coverage.
Pro Tip: If you have a high drug cost and you will meet or exceed the $2100 cap, some insurance companies will allow you to spread out that 2100.00 over 12 months. Essentially you are making 12 payments one each month to cover your 2100.00 out of pocket. This benefit can help those that struggle with paying high dollar co-pays for expensive medications. Please ask your insurance company if they provide this benefit.
3. What Caregivers Should Compare This Year
- Premiums and Out-of-Pocket Costs: Don’t just look at monthly premiums—compare deductibles, copays, and annual limits.
- Drug Coverage: Make sure your loved one’s medications are still covered and check for any formulary changes. It is essential to have an up to date medication list available when reviewing and changing your plan if needed.
- Provider Networks: Confirm that your preferred doctors, specialists, and hospitals remain in-network. Make sure you are weighing the benefits and risks of staying with a provider that may no longer be in network vs. changing doctors to save money.
- Additional Benefits: Look for plans offering extras like dental, vision, transportation, or meal support—especially if needs have changed. These benefits vary greatly and are changing yearly. Since last year when the medication cap (2000) was created, insurance companies were looking for ways to offset this financial responsibility. Many insurance companies trimmed benefits in other areas to prepare to pay more for medications.
- Star ratings: Plans with lower ratings may lose benefits or be discontinued.
4. Annual Enrollment: What You Need to Do
- Review your Annual Notice of Change (ANOC): This document comes from your plan and outlines what’s changing in 2025.
- Compare plans: Even if you’re happy with your current plan, it’s smart to shop around—plans and costs change every year.
- Check for regional changes: Especially if you live in rural Wisconsin, Southeast Minnesota, Northwest Iowa, or Lake County, IL.
- Don’t wait: Enrollment ends December 7, and the earlier you act, the more options you’ll have.
Sintra Image: sharing resources to assist with planning for Medicare Annual Enrollment
5. Resources for Help
- Medicare.gov Plan Finder: https://www.medicare.gov/plan-compare
- Wisconsin Medigap Helpline: 1-800-242-1060
- SHIP (State Health Insurance Assistance Program): Find your local SHIP for free, unbiased counseling
- Your Nurse Advocate Consulting: We offer unbiased, personalized Medicare reviews—contact us for support tailored to your family’s situation.
- Local Aging & Disability Resource Centers (ADRC): Many offer free Medicare counseling and assistance.
- Your Nurse Advocate Consulting Blog Post: This Year’s Medicare Enrollment: What You Need to Know
- Your Nurse Advocate Video: Medicare Annual Enrollment for 2026
- Your Nurse Advocate Consulting Simple Free Checklist to Use to Compare Plans
- Video Interview with Wendi Schoonover, owner of Integrity Insurance Group answering questions on the Medicare Annual Enrollment.
- Recorded Webinar | Navigating Medicare Open Enrollment: Insights for Patients & Caregivers. Center for Medicare Advocacy. Scroll down on the page and you will see the YouTube video to watch.
Medicare decisions can feel daunting, but you don’t have to make them alone. Taking the time to compare plans now can save you stress—and money—down the road. If you need help sorting through your options or understanding what’s changed for 2026, reach out to our team. We’re here to empower you with the information and support you need to make the best choices for your loved ones.
Ready for Annual Enrollment?
Let us know if you’d like a personalized Medicare review or have questions about the new 2026 changes. We’re here to help every step of the way.
Thank you for spending time with us this week. We’re so glad to be part of your journey in caring for your aging loved ones. It’s an honor to share resources, insights, and a little encouragement to support you along the way. We look forward to bringing you more helpful tools and compassionate guidance in the weeks ahead. See you back here soon!
With care,
Pam and Linda
Your Nurse Advocates
“Compassionate Care for Aging Adults Along With Peace of Mind for the Family”
About the Authors
At Your Nurse Advocate Consulting, Pam and Linda’s mission is to empower aging adults and their families to take control of their health, prepare for life’s uncertainties, and secure their peace of mind. We are dedicated to providing compassionate guidance, personalized support, and expert resources to help our clients navigate complex medical needs and organize their personal affairs.
As independent patient advocates we have a steadfast commitment to clarity, family well-being, and empowerment, we strive to make a meaningful impact by ensuring our clients feel confident, prepared, and cared for every step of the way on their healthcare journey.
Expert Guidance You Can Trust
With over 80 combined years of R.N. experience navigating the complex healthcare system, we stand as trusted guides for seniors and their families. Our expertise ensures they can access the care and resources they need without feeling overwhelmed by red tape or confusion.
