2026 Medicare Advantage Rule Changes: What Beneficiaries Need to Know

Overview: The CY2026 Medicare Advantage Final Rule

Every year, the Centers for Medicare & Medicaid Services (CMS) publishes a final rule that sets the regulatory framework for Medicare Advantage (MA) and Part D prescription drug plans for the upcoming contract year. The CY2026 final rule (CMS-4208-F) represents one of the most consequential sets of changes in the program's recent history, addressing long-standing concerns about prior authorization delays, benefit stability, agent misconduct, and care quality for the more than 33 million Americans enrolled in Medicare Advantage.

These changes did not emerge in a vacuum. They follow years of Congressional hearings, Office of Inspector General investigations into improper claim denials, and a rising wave of consumer complaints about plans that marketed generous benefits only to restrict access through administrative hurdles. The 2026 rule aims to tighten oversight while preserving the competitive market structure that has made Medicare Advantage popular.

Whether you are already enrolled in a Medicare Advantage plan, weighing the pros and cons of Medicare Advantage, or helping a family member navigate their options, understanding these rule changes is essential. Here is what is changing and how it affects you.

Prior Authorization Reforms

Prior authorization — the requirement that your insurer approve certain tests, procedures, or medications before you receive them — has been the single largest source of friction between Medicare Advantage enrollees and their plans. An HHS Office of Inspector General report found that 13% of prior authorization denials were for services that actually met Medicare coverage criteria, meaning tens of thousands of beneficiaries were improperly denied or delayed care each year.

The CY2026 rule introduces several targeted reforms to the prior authorization process that will directly impact how quickly you can access care:

• Shorter decision timelines. Standard prior authorization decisions must now be issued within 7 calendar days, down from the previous allowance of up to 14 days. Expedited (urgent) requests must be resolved within 72 hours. For prescription drugs, standard decisions must come within 72 hours and expedited within 24 hours.
• Publicly reported approval and denial rates. Plans must now report their prior authorization approval rates, denial rates, and average processing times. CMS will publish this data, allowing beneficiaries and researchers to compare how aggressively different plans gate access to care. This transparency requirement creates accountability that did not previously exist.
• Continuity of care protections. When an enrollee switches plans — or when a plan's coverage policies change mid-year — previously approved prior authorizations must be honored for a transition period. This prevents the disruptive scenario where a beneficiary's ongoing treatment is suddenly interrupted because a new plan requires re-authorization from scratch.
• Clinical criteria alignment. CMS now requires that the clinical criteria plans use for prior authorization decisions be based on publicly available, evidence-based guidelines. Plans can no longer use proprietary, unpublished criteria to deny care, and they must provide specific, detailed reasons when a request is denied.

What this means for you: If you have ever waited weeks for a test or procedure to be approved, or had a request denied without a clear medical explanation, these reforms provide concrete protections. The transparency measures also mean you can factor a plan's prior authorization track record into your enrollment decisions.

Mid-Year Benefit Change Restrictions

One of the most frustrating experiences for Medicare Advantage enrollees has been discovering that benefits they relied on when choosing a plan in October disappeared or were reduced by the following summer. CMS found that some plans were marketing attractive supplemental benefits during the Annual Election Period, then scaling them back after enrollment locked in — a practice known as "bait and switch" by consumer advocates.

The CY2026 rule addresses this with new guardrails:

• Benefit lock provisions. Plans are now significantly restricted from reducing or eliminating supplemental benefits mid-contract year. The benefits a plan advertises during AEP must remain substantively available through December 31 of that plan year. This applies to dental, vision, hearing, OTC allowances, transportation, meal delivery, and other supplemental benefits.
• Formulary stability requirements. Plans face tighter limits on mid-year formulary changes. While plans can still add drugs to their formulary at any time, removing drugs or moving them to less favorable tiers mid-year now triggers enhanced notice requirements and transition supply provisions so enrollees are not left without their medications.
• Network change notifications. When a provider leaves a plan's network during the contract year, plans must notify affected enrollees within 30 days and provide information about alternative in-network providers. Previously, enrollees sometimes discovered their doctor was out-of-network only when trying to schedule an appointment.

What this means for you: The benefits you see advertised during open enrollment should now be the benefits you actually receive all year. If you chose a plan because of a generous dental allowance or OTC credit, you have stronger assurance that those benefits will not evaporate mid-year.

D-SNP Integration Requirements

Dual Eligible Special Needs Plans (D-SNPs) serve one of the most vulnerable populations in healthcare: people who qualify for both Medicare and Medicaid. These approximately 13 million individuals typically have low incomes, complex health needs, and must navigate two separate insurance systems with different rules, providers, and benefits. The lack of coordination between Medicare and Medicaid has long been recognized as a major source of fragmented care, administrative confusion, and worse health outcomes.

The CY2026 rule strengthens D-SNP integration requirements in several important ways:

• Unified grievance and appeals process. D-SNPs must establish a single point of contact for beneficiaries to file grievances and appeals covering both their Medicare and Medicaid benefits. Previously, dual-eligible enrollees often had to navigate two entirely separate complaint systems, sometimes being told by each side that the other was responsible.
• Coordinated care management. Plans must demonstrate they are actively coordinating benefits across Medicare and Medicaid — including long-term services and supports, behavioral health, and prescription drugs. This means a single, integrated care plan rather than fragmented management.
• Expanded state contracting authority. States gain additional tools to hold D-SNPs accountable through their Medicare-Medicaid contracts (known as MIPPA agreements). States can now set integration benchmarks and require D-SNPs to meet specific care coordination metrics as a condition of operating in the state.

What this means for you: If you or a family member are enrolled in both Medicare and Medicaid, the D-SNP experience should become noticeably less confusing. One phone number for problems, one care team coordinating your benefits, and a state agency with more power to enforce quality standards.

Agent and Broker Compensation Rules

The explosion of Medicare Advantage television ads, robocalls, and aggressive marketing over the past several years prompted CMS to take action. Investigations revealed that some agents and brokers were enrolling beneficiaries in plans without their knowledge or consent, steering them toward plans that paid the highest commissions rather than plans that best fit their needs, or misrepresenting plan benefits to secure enrollments.

The CY2026 rule introduces significant changes to how agents and brokers are compensated and supervised:

• Compensation structure overhaul. CMS has revised the compensation framework to reduce financial incentives for agents to switch enrollees between plans unnecessarily. The rule narrows the gap between renewal commissions (for keeping an existing enrollee) and new enrollment commissions (for switching someone to a new plan), removing the financial motivation to churn enrollees for higher payouts.
• Enhanced oversight of Third-Party Marketing Organizations (TPMOs). The companies behind those "Call now for your Medicare benefits" commercials face stricter CMS oversight. TPMOs must now comply with detailed recording, consent, and documentation requirements. Plans are held directly accountable for the marketing conduct of any TPMO acting on their behalf.
• Explicit consent requirements. Agents must obtain clear, documented consent before enrolling anyone in a plan. The rule tightens what constitutes valid consent and increases penalties for unauthorized enrollments. Beneficiaries who were enrolled without their knowledge have a streamlined process to reverse the enrollment.

What this means for you: If you work with an agent or broker to choose a plan — which many beneficiaries do — these rules provide stronger protections against being steered into an unsuitable plan. When comparing the best Medicare Advantage plans for 2026, you can feel more confident that your agent's recommendation is based on your needs, not their commission.

Network Adequacy Updates

A Medicare Advantage plan is only as good as the providers you can actually see. Network adequacy — whether a plan has enough doctors, specialists, and facilities within a reasonable distance and wait time — has been a persistent concern, particularly in rural areas and for certain specialties like behavioral health, dermatology, and endocrinology.

The CY2026 rule raises the bar for network adequacy in several ways:

• Tighter time and distance standards. CMS is updating the maximum time and distance that enrollees should have to travel to reach specific provider types. Plans in urban areas face stricter standards, and the thresholds for certain specialty types — particularly behavioral health providers — have been tightened to address documented access gaps.
• Appointment wait time standards. For the first time, CMS is establishing enforceable appointment wait time standards for certain provider categories. Having a specialist in your network means little if the earliest available appointment is four months away. Plans must demonstrate not just that providers exist in their network, but that enrollees can access them within a reasonable timeframe.
• Expanded telehealth credit limits. Plans have been allowed to use telehealth providers to partially satisfy network adequacy requirements. The CY2026 rule limits how much telehealth can substitute for in-person provider access, ensuring that enrollees who need face-to-face care — particularly for physical examinations, procedures, and diagnostics — are not directed exclusively to virtual visits.

What this means for you: Plans must maintain broader, more accessible provider networks. You should see more in-network specialists in your area, shorter wait times for appointments, and less reliance on telehealth as a stand-in for providers who should be available in person.

Supplemental Benefit Guardrails

Supplemental benefits — dental, vision, hearing, OTC allowances, meal delivery, transportation, fitness memberships — are a major selling point of Medicare Advantage and a primary reason many beneficiaries choose MA over Original Medicare. However, CMS has identified problems with how some plans design and market these benefits.

The CY2026 rule establishes new guardrails:

• Meaningful benefit standards. CMS is cracking down on plans that advertise supplemental benefits with extremely low dollar values or restrictive conditions that make them nearly impossible to use. Plans claiming to offer dental coverage, for example, must provide benefits that are genuinely useful — not just a $50 annual allowance that covers little more than a fraction of a single cleaning.
• Utilization reporting. Plans must report how many enrollees actually use each supplemental benefit and the average value delivered. This data will help CMS identify plans that advertise benefits primarily as marketing tools rather than genuine services enrollees use and value.
• Clearer marketing disclosures. Plans must clearly disclose the dollar limits, conditions, and network restrictions associated with each supplemental benefit in their marketing materials and Annual Notice of Change. No more burying limitations in fine print while headlining the benefit in advertisements.

What this means for you: The supplemental benefits you see advertised should be more substantive and more clearly described. You will have better information to evaluate whether a plan's dental, vision, or other extras are genuinely valuable or just marketing window dressing.

Star Rating Methodology Changes

The Medicare Advantage Star Ratings system is the primary quality measurement tool for MA plans, rating them on a 1-to-5-star scale across dozens of metrics covering clinical outcomes, patient experience, customer service, and drug plan performance. Star Ratings carry enormous financial stakes: plans rated 4 stars or above receive bonus payments from CMS worth billions of dollars collectively, which they can use to fund richer benefits and lower premiums.

The CY2026 rule makes several notable changes to Star Ratings methodology:

• Greater weight on patient experience. CMS is increasing the weight given to patient experience and access measures — derived from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey — in the overall Star Rating calculation. Measures like "getting needed care" and "ease of getting appointments" will carry more influence.
• Health equity performance measures. New measures evaluating how well plans serve historically underserved populations are being incorporated. Plans will be assessed on whether quality outcomes and access are equitable across racial, ethnic, and socioeconomic groups within their enrollment. This builds on CMS's broader health equity agenda.
• Revised cut points. CMS is adjusting the thresholds (cut points) that determine whether a plan receives 3, 4, or 5 stars on specific measures. As the MA industry has matured, average performance has improved, and the cut points are being recalibrated to ensure meaningful differentiation between plans. Some plans that currently sit at 4 stars may find it harder to maintain that rating.
• Behavioral health quality indicators. Reflecting the growing emphasis on mental health access, new quality indicators related to behavioral health screening, treatment initiation, and follow-up are being added to the Star Rating framework. Plans that neglect mental health access will see their ratings affected.

What this means for you: Star Ratings will become a more reliable indicator of how a plan actually treats its members. When you see a 4- or 5-star plan on the Medicare Plan Finder, you can have greater confidence that it delivers strong access, good outcomes, and equitable care — not just strong performance on clinical process measures that may not reflect your day-to-day experience.

How These Changes Work Together

While each change addresses a distinct problem, the CY2026 rule is designed as an interlocking set of reforms. Prior authorization transparency feeds into Star Ratings, giving plans financial incentives to reduce unnecessary denials. Supplemental benefit guardrails work alongside mid-year benefit restrictions to ensure that what plans promise is what enrollees receive. Agent compensation reforms reduce the pressure that leads to misleading marketing, and network adequacy updates ensure the providers plans advertise are actually accessible.

The cumulative effect should be a Medicare Advantage marketplace where plans compete more on genuine quality and value than on marketing sophistication. For the more than 33 million Americans in Medicare Advantage — and the millions more who will consider it during the next enrollment period — that is a meaningful step forward.

What Beneficiaries Should Do Now

You do not need to take any immediate action in response to these rule changes — they take effect automatically as part of the regulatory framework governing your plan. However, there are several smart steps you can take to benefit from these reforms:

• Review your plan's Annual Notice of Change (ANOC). When your plan sends its ANOC in September, read it carefully. The CY2026 rules mean these documents should be more detailed and transparent about benefits, network changes, and prior authorization policies.
• Compare Star Ratings during AEP. When the updated Star Ratings are released in October, use them as a key comparison tool. With the new methodology placing greater weight on patient experience and health equity, high-rated plans should more accurately reflect a positive enrollee experience.
• Know your prior authorization rights. If your plan denies a prior authorization request, you have the right to a detailed, specific explanation and a faster appeals process under the new timelines. Do not accept vague denials — the rule requires clinical specificity.
• Report problems. If you experience unauthorized enrollment, misleading marketing, benefit reductions, or network access problems, report them to 1-800-MEDICARE or file a complaint on medicare.gov. CMS uses these reports to enforce the new rules and hold plans accountable.
• Contact SHIP for free guidance. Your State Health Insurance Assistance Program offers free, unbiased Medicare counseling. SHIP counselors can help you understand how these rule changes affect your specific situation and whether your current plan still meets your needs.

Frequently Asked Questions

When do the CY2026 Medicare Advantage rule changes take effect? Most provisions take effect for the 2026 contract year, meaning they apply to plans starting January 1, 2026. Some provisions have phased implementation timelines, with full compliance required by 2027 or 2028 depending on the specific requirement. Plans must comply with prior authorization timeline changes and agent compensation reforms beginning with the 2026 plan year.

Will my current Medicare Advantage plan benefits change because of the new rule? The rule itself does not reduce any benefits. It is designed to protect and stabilize the benefits you already have. Plans must still offer at least what they promised during AEP, and the mid-year benefit restrictions make it harder for them to pull back. However, the tighter regulatory requirements could lead some plans to adjust their benefit offerings for the 2027 plan year, particularly if they were relying on thin supplemental benefits as marketing tools.

How do the prior authorization reforms help me if my plan denies a request? Under the new rules, your plan must issue a decision faster (7 days for standard requests, 72 hours for urgent), provide specific clinical reasons for any denial, and use publicly available evidence-based criteria. If you believe a denial is wrong, you can appeal and cite the specific criteria the plan claims you did not meet. The published approval and denial rate data also lets you compare your plan's track record against others.

Do these changes affect Medicare Supplement (Medigap) plans or Original Medicare? No. The CY2026 final rule applies specifically to Medicare Advantage and Part D plans. Original Medicare and Medigap supplement plans are governed by separate rules. However, the changes may indirectly influence enrollment decisions — if Medicare Advantage plans improve their quality and transparency, some beneficiaries on Original Medicare may find MA more appealing, and vice versa.

What should dual-eligible beneficiaries (Medicare and Medicaid) know about the D-SNP changes? If you are enrolled in a D-SNP, the most noticeable change will be improved coordination between your Medicare and Medicaid benefits. You should have a single contact point for grievances and appeals, a more integrated care plan, and your state will have greater authority to enforce quality standards on your D-SNP. These changes are designed to reduce the confusion and fragmented care that dual-eligible individuals have historically experienced.

Will the Star Rating changes cause my plan's rating to drop? It is possible. The revised cut points and increased weighting on patient experience measures mean some plans that currently hold 4 or 4.5 stars may see their rating decrease if their patient experience scores do not keep pace. Conversely, plans that have invested in access, customer service, and health equity may see their ratings improve. Check the updated Star Ratings when they are released each October to see where your plan stands.

How can I check whether an agent or broker is following the new compensation rules? You cannot directly verify an agent's compensation, but you can protect yourself by working with licensed agents, asking them to explain why they are recommending a specific plan, checking the plan independently on the Medicare Plan Finder, and never allowing an agent to enroll you in a plan without your clear, written or recorded consent. If you suspect misconduct, report it to 1-800-MEDICARE (1-800-633-4227).

Where can I read the full CY2026 final rule? The complete final rule is published in the Federal Register and available on CMS.gov. CMS also publishes a fact sheet summarizing the key provisions in plain language. For personalized guidance on how the rule affects your coverage, contact your State Health Insurance Assistance Program (SHIP) — find your local SHIP at shiphelp.org.

The Bottom Line

The CY2026 Medicare Advantage final rule is a significant regulatory step toward a more transparent, accountable, and enrollee-centered Medicare Advantage program. Prior authorization reforms mean faster decisions and clearer reasons when care is denied. Mid-year benefit restrictions mean the plan you chose is the plan you get. D-SNP integration helps the most vulnerable beneficiaries receive coordinated care. Agent compensation changes reduce conflicts of interest. Network adequacy updates ensure you can actually see the providers your plan advertises. Supplemental benefit guardrails demand that extras be genuine, not just marketing. And Star Rating methodology changes make quality scores a more reliable guide for your enrollment decisions.

None of these changes require action on your part right now. But staying informed puts you in a stronger position when it is time to evaluate your coverage during the Annual Election Period. Use the Medicare Plan Finder at medicare.gov/plan-compare to review your options, pay attention to the updated Star Ratings released each fall, and do not hesitate to contact SHIP or 1-800-MEDICARE if you have questions about how these changes affect your plan. An informed beneficiary is a protected beneficiary.