Newsletter

MEDICARE ADVANTAGE PRIOR AUTHORIZATION RULES TIGHTEN IN 2026

CMS (Medicare) rolled out new prior authorization standards for Medicare Advantage plans effective January 1, 2026, and they’re already reshaping how care gets approved. The biggest shift: MA plans must now follow traditional Medicare coverage criteria for most services, reducing the ability of insurers to impose their own internal rules. Plans must also honor prior authorizations for 90 days when a member switches plans, preventing disruptions in ongoing treatment.

Early feedback from providers suggests approvals are moving faster, but beneficiaries should still expect prior authorization for high‑cost imaging, post‑acute care, and many Part B drugs. The rules are better, but documentation still matters. Beneficiaries should notify their doctors early if they anticipate needing a service that typically requires approval.

MEDICARE’S PRESCRIPTION PAYMENT PLAN: NOW IN ITS SECOND YEAR

The Medicare Prescription Payment Plan (referred to as the M3P program) began in January 2025, but many beneficiaries don’t know about this program or that it’s not new for this year. Now entering its second year, the program remains one of the most useful yet least‑understood options in Part D.

It allows enrollees to spread their prescription costs evenly over the year instead of paying large amounts upfront at the pharmacy. This is especially helpful for anyone taking high‑cost medications that once triggered painful spikes in monthly spending.

Enrollment is available year‑round, even after prescriptions have already been filled.

Awareness of this program continues to be low, but beneficiaries have an opportunity to manage cash flow and avoid or reduce surprise pharmacy bills.

NEW MEDICARE ADVERTISING RULES: WHAT HAPPENED DURING THE ANNUAL ENROLLMENT PERIOD (10/7—12/7)— AND WHAT CHANGES IN 2026

CMS (Medicare) has been tightening Medicare Advantage and Part D marketing rules, but the rollout has occurred in two phases — and the difference matters.

What CMS Enforced During the 2025 Annual Enrollment Period

During AEP 2025, CMS began early enforcement of several high‑priority rules. These were not yet the full regulatory package, but CMS targeted the most misleading practices, including:

• Stopping ads that used generic “Medicare hotline” language
• Requiring advertisers to clearly identify the specific plan being promoted
• Prohibiting imagery or wording that suggested Medicare endorsement
• Cracking down on ads implying benefits are available everywhere

CMS issued warnings, required ad revisions, and monitored call centers more closely — but this was still considered a transition period, not full implementation.

What Became Mandatory as of January 1, 2026

Starting 1/1/2026, the entire updated rule set became fully enforceable. This year, CMS is requiring:

• Full compliance with all new advertising standards, not just the high‑risk items

• Pre‑approval of certain marketing materials before they can be used

• Stricter oversight of third‑party marketing organizations (TPMOs)

• Clearer disclaimers, including when benefits vary by county or plan

• More aggressive penalties for misleading or incomplete information

• Zero tolerance for ads that obscure plan names, exaggerate benefits, or mimic government communications

In short:

• AEP 2025 = early enforcement + warnings + partial rule application



• 2026 = full enforcement + full rule set + stronger penalties + mandatory compliance for all marketing

Beneficiaries still complain about unsolicited calls concerning enrollment in Medicare Advantage and Part D plans. Let’s hope that Medicare can crack down and reduce the volume of these calls. This is tough for Medicare to handle, however, as many of these calls are coming from foreign call centers.

About Paul Cholak

Paul is a licensed, independent health and life insurance agent and has over forty years of benefits experience and specializes in helping Medicare beneficiaries obtain health insurance. However, he offers a complete array of life and health insurance products to individuals of all ages.

He guides Medicare beneficiaries through the steps of getting insurance and is available to help clients both BEFORE and AFTER they've made their purchase decision.

Disclaimer for Part C and D plans: "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 (TTY: 1-877-2048) to get information on all your options."

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