Other Changes to Medicare Coverage in 2026
Part 4 in the NASW Series Helping Medicare Beneficiaries Plan for & Navigate Coverage in 2026
Chris Herman, MSW, LICSW
Senior Practice Associate–Aging
December 2025
Introduction
This
Tips & Tools for Social Workers is the last in a four-part series addressing Medicare annual enrollment and changes to Medicare in 2026. It addresses the following topics:
introduction of artificial intelligence (AI)–powered prior authorization to original Medicare (the “WISeR” pilot program)
- limitations on supplemental benefits available under Medicare Advantage (MA) plans
- impact of decreased commissions for MA and Part D agents and brokers may affect beneficiary enrollment
- impact of the July 2025 budget reconciliation law (P.L. 119-121, also known as H.R. 1) on Medicare in 2026 and beyond—specifically, the exclusion of many immigrants with “lawfully present” status from coverage, decreased nursing home staffing and quality, and potential funding reductions to the Medicare program
- Medicare coverage of telemental health services
- resource list
Please visit https://bit.ly/NASW-MedicareAEP25 to read the other three publications in this series:
Part 1—Medicare Annual Enrollment Basics & the Social Work Role
Part 2—Navigating Medicare Annual Enrollment for 2026
Part 3—Out-of-Pocket Health Costs & Financial Assistance for Medicare Beneficiaries in 2026
Introduction of AI-Powered Prior Authorization to Original Medicare
On January 1, 2026, a pilot program called the “Wasteful and Inappropriate Service Reduction (WISeR) Model” will launch in six states: Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington (Centers for Medicare & Medicaid Services [CMS], 2025b). The model will run through December 31, 2031 (CMS, 2025b).
According to CMS Administrator Mehmet Oz, the model “will help root out waste in Original Medicare, … protecting Medicare beneficiaries from being given unnecessary and often costly procedures” (CMS, 2025a, para. 2). CMS plans to use “enhanced technologies, such as Artificial Intelligence (AI) and Machine Learning (ML), along with human clinical review,” to achieve this goal (CMS, 2025a, para. 1).
CMS’s Center for Medicare and Medicaid Innovation (Innovation Center) selected items and services within 14 categories, comprising 50 procedural codes and hundreds of associated codes, for inclusion in the WISeR Model (Innovation Center, 2025, Appendixes A & B). Moreover, CMS chose six technology companies to administer the AI-powered prior authorization program (Trang, 2025).
A CMS fact sheet provided the following information about the model:
WISeR does not change Medicare coverage or payment policy. Health care coverage for people with Medicare will not change, and they retain the freedom to seek care from their Original Medicare provider or supplier of choice. Payment to providers and suppliers for covered items and services will not change under the model. …
Providers and suppliers for people with Original Medicare in selected regions will have the choice of submitting a prior authorization request for the model’s selected items and services or go through a post-service/pre-payment medical review. Those that choose the prior authorization route may either submit the prior authorization request (a) directly to the model participant or (b) to their Medicare Administrative Contractor (MAC) that will forward the request to the model participant. If they opt not to submit a request for an included service, their claim will be subject to medical review by the model participant to ensure the delivered service met Medicare coverage, coding, and payment criteria prior to payment. (Innovation Center, n.d.-b, p. 1)
According to beneficiary advocates, however, the WISeR model is likely to impede access to care and services. Although CMS has stated that the model will “safeguard federal taxpayer dollars” (CMS, 2025a, para. 1), AARP pointed out that “technology companies that participate will be paid based on savings from denied medical claims, which has drawn the ire of the American Medical Association and consumer organizations” (Pugh, 2025, sec. 5, para. 4). Moreover, AARP stated:
The pilot project comes amid concerns from lawmakers, government watchdogs and others that Medicare Advantage plans’ prior authorization procedures can create burdens for caregivers, who have to figure out how to appeal, and risk the health of patients by delaying or denying care that would otherwise be covered under original Medicare. (Pugh, 2025, sec. 5, para. 5)
Likewise, Center for Medicare Advocacy (CMA) founder Judy Stein asserted, “The program creates a barrier between what physicians and other healthcare providers order… and what can be provided based on algorithms” (Washington, 2025, sec. 3).
NASW shares these advocates’ apprehensions about the pilot program. As a member of the Coalition to Preserve Rehabilitation (CPR, https://preserverehab.org/), the association signed on to a letter to CMS expressing “serious concerns” about “the potential unintended consequences of the WISeR Model,” (ACCSES et al., 2025, p. 1), the letter concluded:
CPR strongly urges CMS to reconsider the structure and implementation of the WISeR Model. At a minimum, we recommend that CMS delay implementation of this program and seek robust public input to ensure that any program that seeks to monitor medical necessity of traditional Medicare services puts patient access first. CMS must clearly define the clinical qualifications required of reviewers of all services included in this program, especially medical rehabilitation services, ensure meaningful public reporting and transparency, revise the participant payment methodology to prioritize patient outcomes over financial incentives to deny access, and establish stakeholder engagement mechanisms to inform ongoing oversight. Absent these and other meaningful changes to this program, the WISeR model threatens to disrupt access to care for patients who rely on key Medicare services, including medical rehabilitation services and therapies to restore Medicare beneficiary’s health, function, and maintain independence. (ACCSES et al., 2025, p. 3)
An article published in Ohio (one of the six states participating in the WISeR demonstration) offered the following advice for beneficiaries who may be affected by implementation of the model: “Confirm whether you have original Medicare, check if your procedures are on the targeted list, and talk to your provider about the new process. … If a claim is denied, it is crucial to stick with the appeals process” (Washington, 2025, sec. 5).
Visit https://medicareadvocacy.org/medicare-prior-authorization/ to learn more about Medicare prior authorization (not specific to WISeR).
Limitations on Supplemental Benefits Available under MA Plans
The MA Value-Based Insurance Design (VBID) Model will end on December 31, 2025, because of unsustainably high costs (CMS, 2024). During the nine years of VBID operation, participating MA plans were able to provide to eligible enrollees—especially beneficiaries with low incomes—tailored supplemental benefits (such as grocery assistance, transportation services, support managing chronic health conditions, and decreased prescription drug costs) as a strategy to promote health and access to health care (Innovation Center, n.d.-a).
Special Supplemental Benefits for the Chronically Ill (SSBCI) will continue in 2026, but with limitations. As specified in Section 1852(a)(3)(D)(ii)(I) of the Social Security Act, SSBCI must “have a reasonable expectation of improving or maintaining the health or overall function of the chronically ill enrollee.” In a federal regulation finalized this past April, CMS finalized a “non-exhaustive list of nonprimarily health related items or services” that may not be offered as SSBCI in 2026:
- procedures that are solely cosmetic in nature (such as cosmetic treatment for facial lines)
- alcohol, tobacco, and cannabis products
- funeral planning and expenses
- life insurance
- hospital indemnity insurance
- broad membership-type programs inclusive of multiple unrelated services and discounts (such as Amazon Prime and Costco)
- “non-healthy food,” which CMS defines only as “food that does not assist in meeting the nutritional needs of a chronically ill enrollee” (42 C.F.R. § 422.102, 2025, pp. 15867–15868)
These changes to SSBCI and VBID do not eliminate the availability of supplemental benefits. However, they reinforce the importance of careful research for any beneficiary who considers staying or enrolling in an MA plan. Availability of and eligibility for MA supplemental benefits varies greatly, and inclusion of benefits in a particular plan does not guarantee a plan enrollee’s access to those benefits. As the Medicare Rights Center (MRC) has noted, “Two beneficiaries enrolled in same plan may have access to different supplemental benefits, depending on their health status and plan design (Ayeh, 2025).
Information about newly enhanced descriptions of MA supplemental benefits in the Medicare Plan Finder is included in Part 2 of this Tips & Tools series, “Navigating Medicare Annual Enrollment for 2026.”
Changes to Commissions for MA Agents and Brokers
In October, CMA reported that numerous large Medicare Advantage and Part D carriers had decided to stop paying commissions to agents and brokers for enrolling Medicare beneficiaries “in many, or in some cases, all, of their Medicare Advantage and standalone Part D plans” (Lambert, 2025, Broker commission confusion section). CMA went on to cite three articles (Rupe, 2025; Wilson, 2024; Young & Tepper, 2025) announcing discontinuation of such broker commissions by the following insurers: Aetna, Cigna, Humana, UnitedHealthcare, Wellcare, and Wellpoint/Elevance/Anthem. A CNBC article cited by CMA stated that, “For 2026 open enrollment, 15% to 20% of plans have been decommissioned across most of the country,” with decommissions for more than 25 or even 35 percent of plans in some parts of the country (Coombs, 2025, Insurers decommission plans section, para. 4).
As a result of this decommissioning, CNBC reported, CMS anticipated that MA enrollment would drop from 35 million in 2025 to 34 million in 2026 (Coombs, 2025, Key point 1). Of greater concern, CMA noted in its report, was a Fortune article forecasting that agents might not be willing to sell (or even renew) MA or Part D plans for which they won’t receive commission, even when those plans are in the beneficiaries’ best interest—in other words, that agents will steer beneficiaries to plans that garner profit for themselves (Eisenberg, “What it means” section). CMA reported that such steering had occurred in Connecticut, with some beneficiaries being told falsely that certain continuing plans were no longer available and others being encouraged to remain in an existing plan so the broker could earn a renewal commission (Lambert, 2025, Broker commission confusion section).
NASW concurs wholeheartedly with CMA’s recommendation (Lambert, 2025) that Medicare beneficiaries work with the publicly funded State Health Insurance Assistance Program (SHIP) for expert, free, unbiased advice on all Medicare enrollment options. Part 2 of this Tips & Tools series provides more information about SHIP.
Exclusion of Many “Lawfully Present” Immigrants from Coverage
As explained in a previous edition of NASW Tips & Tools (Herman, 2025), immigrants without documentation are already ineligible for Medicare, Medicaid, subsidized Health Insurance Marketplace coverage (premium tax credits), and the Supplemental Nutrition Assistance Program (SNAP) (Altman et al., 2025). The July 2025 budget reconciliation act (P.L. 119-21) restricts eligibility for these benefits to the following groups of immigrants:
- lawful permanent residents, or “LPRs”—that is, people with green cards
- certain immigrants from Cuba and Haiti who are classified as “Cuban–Haitian Entrants”
- people residing in the United States under a Compact of Free Association (COFA) with the Republic of the Marshall Islands, the Federated States of Micronesia, and the Republic of Palau, also known as COFA migrants (National Immigration Law Center, as cited in Altman et al., 2025)
Thus, the previous NASW Tips & Tools clarified:
Immigrants residing lawfully in the United States who will lose Medicaid, Medicare, CHIP, and subsidized Marketplace coverage include—but are not limited to—refugees and asylees; people who have experienced trafficking or domestic violence; people with Temporary Protected Status (TPS); and people under the Deferred Action for Childhood Arrivals (DACA) program (Altman et al., 2025; Bers, 2025). (Herman, 2025, “Disproportionate impact” section)
These exclusions will apply even for people who have paid into the Medicare system (Carter, 2025b).
People born outside the United States who had not yet enrolled in Medicare became ineligible for the program immediately upon enactment of the law (July 4, 2025). Current Medicare beneficiaries who do not meet the new requirements will be notified by Social Security in July 2026 of their impending loss of coverage and will be terminated from the Medicare program on January 4, 2027 (Altman et al., 2025; Coleman et al., 2025). CBO (as cited in Coleman et al., 2025, Rise in the uninsured section) has estimated that 100,000 people will lose Medicare coverage as a result of this law. (Please refer to Kean & Huyenh-Cho, 2025, for more information about Medicare and immigrants.)
Eligibility changes for Medicaid (and CHIP) will take effect even sooner—on October 1, 2026 (Altman et al., 2025; Association of State and Territorial Health Officials, 2025). As a result, some Medicare beneficiaries who are immigrants will lose access to Medicare Savings Programs (addressed in Part 3 of this Tips & Tools series, “Out-of-Pocket Health Costs & Financial Assistance for Medicare Beneficiaries in 2026”) or more comprehensive Medicaid coverage months before they lose Medicare coverage. (Please refer to Artiga et al., 2025, for the full list of “qualified non-citizens” who currently qualify for Medicaid and CHIP.)
Decreased Nursing Home Staffing & Quality
Another consequence of the July 2025 budget reconciliation act is the ban on the federal government’s implementation of the Nursing Home Minimum Staffing Rule (2024), which set minimum staffing requirements for certified nurse aides, licensed practical nurses, and registered nurses who provide care directly to residents of Medicaid-funded nursing facilities and Medicare-funded skilled nursing facilities (National Consumer Voice for Quality Long-Term Care [Consumer Voice] et al., 2025). Although the staffing standards in this rule were modest in relation to what NASW and other resident and workforce advocates had sought (e.g., Bedney, 2023; Edelman, 2023; Smetanka, 2022), the rule had been estimated to save the lives of 13,000 residents over a decade (Werner & Coe, 2024). In late August, CMS sent an interim final rule, Repeal of Minimum Staffing Standards for Long-Term Care Facilities, to OMB for review (https://www.reginfo.gov/public/do/eoDetails?rrid=1077065); by that time, the rule had already encountered multiple legal challenges by the nursing home industry (Consumer Voice, 2025; Edelman, 2025; Mullaney, 2025). At the time of this publication, OMB had not finished reviewing the rule. When OMB review is complete, the interim final rule will be posted to CMS’s newsroom page (https://www.cms.gov/about-cms/contact/newsroom) and in the Federal Register (https://www.federalregister.gov/agencies/centers-for-medicare-medicaid-services).
Potential Program Funding Reductions in 2026 & Beyond
As described in Part 3 of this Tips & Tools series, CBO (as cited in Cubanski et al., 2023) projected that the Medicare Drug Price Negotiation Program in the Inflation Reduction Act of 2022 (P.L. 117-169) would save $98.5 billion for the Medicare program between 2022 and 2031. In contrast, the July 2025 budget reconciliation act will increase Medicare spending by almost $4 billion and will increase OOP prescription drug costs for beneficiaries (Copeland, 2025b). As noted in NASW’s Tips & Tools addressing the July 2025 budget reconciliation act (Herman, 2025), P.L. 119-21 will trigger sequestration (reduction) of about $500 billion to the Medicare program as a whole from federal fiscal year (FY) 2026 (which began on October 1, 2025) through FY 2034 (September 30, 2035), with a cut of $45 billion in FY 2026 alone (Carter, 2025a). These cuts would not only reduce payments to Medicare plans, providers, and suppliers (Rosso, 2023), but would also jeopardize the sustainability of the Medicare program (CMA et al., 2025). Congress can delay these cuts, as it has in the past (Justice in Aging, 2025). Nonetheless, MRC has asserted, the law “paves the way for bigger Medicare rollbacks by ballooning the national debt. … Rising deficits would further jeopardize Medicare’s long-term outlook by creating a funding hole that lawmakers could use as an excuse to pursue future program cuts” (Copeland, 2025a, para. 15). More specifically, the nonpartisan, nonprofit Committee for a Responsible Federal Budget (CRFB) has estimated that the new budget law will accelerate Medicare insolvency by a year (from 2033 to 2032), resulting in cuts to the program (CRFB, 2025).
Telemental Health Services
On November 12 COVID-19-era Medicare flexibilities for mental health services provided using telehealth were extended through January 30 as a result of the Continuing Appropriations, Agriculture, Legislative Branch, Military Construction and Veterans Affairs, and Extensions Act, 2026 (P.L. 119-37). NASW continues to advocate to make these flexibilities permanent (NASW, 2025a, 2025b). Please monitor the following NASW webpages for updates about telehealth:
Please refer to Part 1 of this series, “Medicare Annual Enrollment Basics & the Social Work Role,” for information about how social workers can help beneficiaries navigate the AEP and understand coverage for 2026.
Resources
CMS
Information & Enrollment
Medicare & You handbook (includes information about Medicare coverage and enrollment; help paying for out-of-pocket health costs; and beneficiary rights and protections): https://www.medicare.gov/medicare-and-you
Medicare Plan Finder (can be used to compare coverage options and to enroll; please refer to Part 2 of this series cautionary information regarding Medicare Advantage supplemental benefits and provider directories within Plan Finder): https://www.medicare.gov/plan-compare
Phone: 1-800-MEDICARE (1-800-633-4227)
TTY: 1-877-486-2048
Live chat: https://www.medicare.gov/talk-to-someone
CMS personnel are available to provide live support by phone, TTY, or chat 24 hours a day, 7 days a week, except for some federal holidays.
Beneficiary-Oriented Educational & Outreach Materials for the Medicare AEP
Medicare AEP Information & Training for Professionals
In previous years, CMS hosted a two-hour webinar through its National Medicare Education Program (NMEP) and two half-day trainings through its National Training Program (NTP). The Trump Administration has suspended NMEP meetings, closed the NTP, and removed archived NTP materials from the CMS website.
CMS retains one webpage oriented toward partners (professionals). At the time of this Tips & Tools publication, the CMS webpage provided limited, basic information about AEP, with links to the beneficiary-oriented educational and outreach materials listed previously. https://www.cms.gov/priorities/key-initiatives/medicare-open-enrollment-partner-resources
Additionally, CMS posted customizable slides about the current AEP; visit https://www.cms.gov/files/document/medicare-general-oe-outreach-customizable-oct-2025-final-508c.pptx to download this content.
Medicaid
Find a local office (for Medicare Savings Program enrollment): https://www.medicaid.gov/about-us/where-can-people-get-help-medicaid-chip#statemenu
Phone: 1-877-267-2323
TTY: 1-800-877-8339
Social Security Administration
Part D Extra Help (Low Income Subsidy) application: https://www.ssa.gov/medicare/part-d-extra-help
Phone: 1-800-772-1213 (8 a.m.–7 p.m. ET, Monday–Friday)
TTY: 1-800-325-0778
Find a local office: https://secure.ssa.gov/ICON/main.jsp
Similar to 1-800-MEDICARE, the Social Security Administration’s call center remained staffed during the federal shutdown. However, services in local offices were reduced, and a backlog may exist for beneficiaries seeking help with LIS enrollment.
Other Federally Funded Resources
State Health Insurance Assistance Program (SHIP)
https://www.shiphelp.org/SHIPs/
Phone: 1-877-839-2675
Senior Medicare Patrol (SMP)
https://smpresource.org/ (Click “Find Help in Your State”)
Phone:
1-877-808-2468
State Pharmaceutical Assistance Programs (SPAPs)
https://www.medicare.gov/plan-compare/#/pharmaceutical-assistance-program/states?year=2025&lang=en
AIDS Drug Assistance Program (ADAP)
https://adap.directory/directory
National, Nonprofit, Beneficiary-Focused Organizations
Center for Medicare Advocacy
https://medicareadvocacy.org/
Medicare Rights Center
https://www.medicarerights.org/
National Helpline for beneficiaries: 1-800-333-4114 (Press 8 for Spanish)
Justice in Aging
https://justiceinaging.org/
National Council on Aging
BenefitsCheckup®: https://benefitscheckup.org/ & 1-800-794-6559
Benefits Enrollment Centers: https://www.ncoa.org/article/what-are-becs/
BenefitsCheckup® and Benefits Enrollment Centers receive both federal and private funding.
Relevant Content Excluded from This Series
Please visit NASW’s Practice Alert for the fall 2022 Medicare annual enrollment period (https://bit.ly/NASW-MedicareOEP22) for an overview of the following Medicare coverage options:
- Medicare Part A and Part B (original Medicare)
- Medicare Part D
- Medigap, also known as Medicare supplemental insurance
- Medicare Advantage—privatized plans, such as such as Health Maintenance Organization (HMO) plans and Preferred Provider Organization (PPO) plans; also known as Part C
- Program of All-Inclusive Care for the Elderly (PACE)
Terminology Used in This Series
The autumn Medicare annual election (enrollment) period (AEP, also known as the annual coordinated election period) is often referred to as the Medicare Open Enrollment Period (OEP) or Medicare open enrollment. In previous years, NASW used the “open” terminology for consistency with public-facing messaging from CMS. However, some beneficiary advocates have used the terms “annual enrollment” and “AEP” to distinguish the autumn enrollment period for all Medicare beneficiaries with the Medicare Advantage OEP (January 1 through March 31); likewise, some CMS materials have incorporated this change. For this reason, NASW uses “annual enrollment” or AEP throughout this series, other when quoting other materials, and we will continue to use this terminology going forward.