Upcoming adjustments to Medicare in the year 2026
In the wake of the Inflation Reduction Act of 2022 (IRA), the Trump administration during its second term has seen limited direct changes related to Medicare benefits and management. Instead, the focus has been on broader healthcare and Medicaid policy shifts.
One of the most significant updates introduced by the IRA is the historic reduction in prescription drug costs under Medicare. The act introduced caps on out-of-pocket spending in Part D, capped insulin costs, and reduced the Part D deductible. However, the Trump administration's response to these IRA provisions has involved some maneuvers to limit drug price negotiations, specifically by expanding exemptions for orphan drugs.
The Orphan Cures Act, passed under the Trump administration, broadened exemptions for drugs used for rare diseases (orphan drugs), increasing the number of high-cost drugs excluded from negotiation under Medicare Part D. This impacts drugs like Keytruda and Opdivo, important oncology medications with multiple orphan designations.
Regarding prescription drug costs, the IRA implemented caps on annual out-of-pocket Part D spending at $2,000 and capped insulin costs at $35 per month. While these protections technically remain effective, the Trump administration's approach has focused on regulatory modifications that may blunt their scope.
In terms of prior authorizations within traditional Medicare, the Trump administration has maintained or increased procedural requirements like prior authorization, especially in efforts to control costs and expand oversight. However, detailed recent policy changes specific to prior authorization for traditional Medicare under the Trump administration after the IRA are sparse in available data.
The Trump administration has deprioritized or rescinded some Biden-era Medicaid expansions like health-related social needs waivers and continuous eligibility waivers, which indirectly affect Medicare beneficiaries by constraining Medicaid support and care continuity for dual eligibles (those enrolled in both Medicare and Medicaid).
In summary:
| Medicare Aspect | Status/Change Under Trump Administration Post IRA (2025) | |---------------------------------|----------------------------------------------------------------------------------------| | Prescription Drug Costs (Part D) | IRA caps on out-of-pocket and insulin remain, but expanded orphan drug exemptions limit price negotiations[4]. | | Part D Deductibles | IRA reduced deductibles; impact stable but negotiation exemptions may slow further savings[4]. | | Insulin Costs | IRA $35 monthly cap in place; no major Trump-led rollback reported. | | Prior Authorizations (Traditional Medicare) | Continued use/increase of prior authorizations; no specific rollbacks post IRA documented[1][2]. | | Medicaid Overlap (Dual Eligibles) | Trump administration rescinded some continuous eligibility and social needs waivers, affecting coverage stability for some Medicare beneficiaries with Medicaid[2]. |
Moving forward, prior authorizations for traditional Medicare will be implemented in six states (New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington) starting from January 1, 2026, using the Wasteful and Inappropriate Service Reduction (WISeR) Model. The limit on special supplemental benefits for the chronically ill (SSBCI) on Medicare Advantage plans has not been specified in the provided text.
Lastly, the Trump administration has moved forward with the Medicare price negotiations, but has declined to cover GLP-1 receptor agonists, which the previous administration had supported.
For those seeking assistance in reviewing options and finding the Medicare Advantage plan that best matches their needs, beneficiaries can locate their state SHIP program (State Health Insurance Assistance Program). It's also recommended to check coverage each year to stay informed about changes in costs, benefits, and providers, which could help find better coverage or save money. If beneficiaries are satisfied with their current coverage, they do not need to take any action during the annual review period.
- The Trump administration's response to the prescription drug cost reductions introduced by the Inflation Reduction Act has involved expanding exemptions for orphan drugs, which may limit the scope of price negotiations.
- In terms of Medicare Advantage plans, the Trump administration has declined to cover GLP-1 receptor agonists, a type of medication that the previous administration had supported.
- For those seeking help in reviewing and finding the best Medicare Advantage plan to meet their needs, it is recommended to locate the State Health Insurance Assistance Program (SHIP) in their state, and to check coverage annually to stay informed about changes and potential savings.
