Out-of-Pocket Health Costs & Financial Assistance for Medicare Beneficiaries in 2026

Part 3 in the NASW Series Helping Medicare Beneficiaries Plan for & Navigate Coverage in 2026
Chris Herman, MSW, LICSW
Senior Practice Associate–Aging

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December 2025

Introduction

This Tips & Tools for Social Workers is the third in a four-part series addressing Medicare annual enrollment and changes to Medicare in 2026. It addresses the following topics:

• beneficiary cost sharing amounts for Part A, Part B, Medigap, Part D, and Medicare Advantage (MA) coverage in 2026
• Medicare coverage of medications (including the Monthly Prescription Payment Plan and price-negotiated drugs), vaccines, and certain health screenings and tests
• government-funded programs that assist Medicare beneficiaries with out-of-pocket (OOP) health costs: Medicare Savings Programs (MSPs), Part D Extra Help (Low-Income Subsidy, or LIS), the Limited Income Newly Eligible Transition (LI NET) program, State Pharmaceutical Assistance Programs (SPAPs), and the AIDS Drug Assistance Program (ADAP)
• nongovernmental resources for OOP health costs
• 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 4—Other Changes to Medicare Coverage in 2026

Beneficiary OOP Costs for 2026

Part A and Part B

Each year, the Centers for Medicare & Medicaid Services (CMS) determines standard amounts most beneficiaries will pay for premiums, deductibles, and coinsurance in Part A and Part B. CMS released a fact sheet in mid-November (CMS, 2025f) announcing the following information for 2026.

Part A Deductibles & Coinsurance

• inpatient hospital annual deductible: $1,736 ($60 more than in 2025) (CMS, 2025f)
• daily coinsurance for the 61st through 90th inpatient hospital day: $434 (an increase of $15 from 2025)
• coinsurance for each lifetime reserve day in an inpatient hospital: $868 (a $30 increase; each beneficiary’s 60 lifetime reserve days may be split across any hospitalizations that exceed a 90-day benefit period but can only be used one time—a sort of debit model throughout a beneficiary’s lifetime, as explained in Medicare Rights Center, 2025f)
• skilled nursing facility coinsurance: $217 (an increase of $10.50) (CMS, 2025f)

Part A Premiums

According to CMS (2024e), 99 percent of beneficiaries do not pay a monthly premium for Part A because either they or their spouse paid sufficient Medicare taxes while working. In the past, CMS has provided detailed information to help beneficiaries determine whether they qualify for premium-free Part A; however, that information had not been updated for 2026 at the time of this publication (CMS, n.d.-w). For beneficiaries who do pay premiums, costs will increase by either $26 or by $47 per month (to $311 or $565, respectively), depending on the beneficiary’s work history (CMS, 2025f).

People who do not qualify for premium-free Part A may also wish to check ACA state or federal marketplaces (https://www.healthcare.gov/get-coverage/) to determine whether they qualify for a subsidy on a non-Medicare plan. However, these plans may also be inaccessible to many people if Congress does not extend or make permanent enhanced premium tax credits for ACA health plans (Copeland, 2025; Schwarz, 2025b).

Part B Deductible

The annual deductible for all Medicare Part B beneficiaries in 2026 will be $283—an increase of $26 from 2025 (CMS, 2025f).

Premiums for Full Part B Coverage

The CMS fact sheet (2025f) has provided the following information regarding Part B premium costs in 2026:

• The standard Part B premium in 2026 will be $202.90 per month, an increase of $17.90 from 2025. According to CMS, this standard premium applies to 92 percent of beneficiaries—specifically, those with a modified adjusted gross income (MAGI) of $109,000 or less for beneficiaries filing individual income taxes and of $218,000 for beneficiaries filing income taxes jointly.
• Beneficiaries with higher incomes will pay higher monthly premiums, as outlined in the fact sheet; the difference between the standard and higher premiums is known as the income-related monthly adjustment amount, or IRMAA. (For purposes of determining IRMAA, MAGI tiers above the $109,000 threshold vary for any beneficiary who is married and lives with a spouse at any time during the taxable year, but who files tax returns separately from their spouse.) (CMS, 2025f)

Premiums for Part B Coverage of Immunosuppressive Drugs

CMS offers Part B coverage solely for immunosuppressive medications. Similar to premiums for full Part B coverage, IRMAA requires beneficiaries in upper-income tiers to pay higher premiums for this immunosuppressive drug coverage (CMS, 2025f). In 2025, the spaces between those income tiers were smaller for Part B immunosuppressive drug coverage only than it was for full Part B coverage (CMS, 2024e); in 2026, however, income tiers for both types of Part B coverage will be identical (CMS, 2025f). Likewise, MAGI tiers beyond $109,000 vary for any beneficiary who is married and lives with a spouse at any time during the taxable year, but who files tax returns separately from their spouse.

Reduced monthly premiums will remain available in 2026 to certain beneficiaries who are no longer eligible for full Medicare coverage because they had a kidney transplant at least 36 months ago (CMS, 2025f). (This change took effect in 2023.) These beneficiaries can continue Part B coverage solely for immunosuppressive drugs by paying a monthly premium of $121.60, an increase of $11.20 from 2025 (CMS, 2025f).

Medigap

As described in a previous NASW publication addressing the Medicare AEP (Herman, 2022), beneficiaries enrolled in original Medicare may purchase one of 10 Medigap plans, each identified by a letter of the alphabet and (potentially) sold by multiple insurance companies. (Visit https://www.medicare.gov/health-drug-plans/medigap/basics/compare-plan-benefits to learn more about Medigap policies, also known as “Medicare supplemental insurance.”)

In most parts of the United States, a high-deductible option is currently available for three types of Medigap plans: Plan F, Plan G, and Plan J (CMS, 2025a). Each year, CMS establishes a high-deductible option amount for those three plans. (For details regarding high-deductible plan eligibility and availability, please refer to NASW’s Tips & Tools addressing the fall 2024 Medicare AEP, https://bit.ly/NASW-MedicareOEP24.) The high-deductible amount for all three plans will be $2,950 in 2026 (CMS, 2025a).

Likewise, CMS establishes annual limits on OOP spending for beneficiaries enrolled in Plan K and Plan L. In 2026, the limit will be $8,000 for Plan K and enrollees and $4,000 for Plan L enrollees (CMS, 2025c).

Medicare Advantage

CMS has projected that the average monthly premium for MA plans will be $14.00 per month in 2026 (a $2.40 decrease from the 2025 average monthly premium of $16.40) (CMS, 2025e). Fact sheets outlining the availability of MA plans and average MA premium costs for each state and for the District of Columbia and Puerto Rico in 2026 have been posted on the CMS website (CMS, 2025d). These fact sheets exclude American Samoa, Guam, Northern Mariana Islands, and the U.S. Virgin Islands, where MA plans are not available.

2026 OOP Costs for Prescription Drugs, Vaccines, & Certain Health Screenings & Tests

Part D Premiums

CMS does not set standardized premium amounts for PDPs (Center for Medicare Advocacy [CMA], n.d., The Part D Standard Benefit section, para. 6). At the same time, CMS does limit the amount by which PDP monthly premium may increase; this amount will be $50 in 2026, $15 greater than the 2025 limit (Klomp, 2025). (As CMA has observed, this increase is a consequence of the Trump administration’s attempt to undermine stand-alone Part D plans in favor of MA plans [Lipschutz, 2025b].)

CMS has projected that the average total monthly premium for stand-alone Part D plans will be $34.50 in 2026, a decrease of $3.81 from 2025 (CMS, 2025e). However, Part D premiums vary greatly and are influenced by multiple factors, such as geography, plan formulary, and plan deductible, copayments, and coinsurance amounts. CMS (2025d) has posted fact sheets outlining the Part D plan landscape for each state, the District of Columbia, American Samoa, Guam, Northern Mariana Islands, Puerto Rico, and the U.S. Virgin Islands.

Another significant factor in determining Part D premiums is beneficiary income (CMS, n.d.-o). Each November, the Social Security Administration usually mails to beneficiaries with higher incomes notice of IRMAA premiums for the upcoming calendar year (CMS, n.d.-u, 2025b; Medicare Rights Center [MRC], 2025g; Social Security Administration, 2011). In 2026, IRMAA premiums will range from $14.50 to $91 per month, depending on a beneficiary’s income tier and marital status; the tiers will match those of Part B (CMS, 2025f).

Prescription Drug Deductible & Annual Spending Cap

Beneficiaries’ maximum OOP cost sharing on Part D–covered prescription drugs in 2026 will be $2,100, without a coverage gap or “doughnut hole” (CMS, n.d.-l). This $2,100 OOP spending cap applies to both stand-alone prescription drug plans and to MA prescription drug plans. The Part D benefit has three phases (a redesign that took effect in calendar year 2025): annual deductible, initial coverage period, and catastrophic coverage period.

Annual Deductible

The beneficiary pays the full cost of eligible Part D–covered prescription drugs until the deductible is met. The maximum Part D annual deductible a plan may charge in 2026 will be $615, an increase of $35 as compared to 2025 (CMS, n.d.-l). Deductibles vary by plan, and some plans cover certain prescription drugs before the beneficiary meets the deductible (CMS, n.d.-l). The deductible cost counts toward the OOP maximum (MRC, 2025m).

Initial Coverage Period

After meeting the deductible, the beneficiary pays 25 percent of the cost of most Part D–covered prescription drugs (or up to 33 percent of the cost of specialty tier drugs) until reaching the OOP spending cap of $2,100 (CMS, n.d.-l). This threshold applies to all Medicare beneficiaries enrolled in a stand-alone Part D plan or an MA plan prescription drug plan, regardless of income level (PAN Foundation, n.d.).

The following OOP spending (sometimes known as True Out-of-Pocket Costs, or “TrOOP”) count toward the $2,100 spending cap:

• annual deductible (MRC, 2025i)
• all copayments or coinsurance for Part D–covered prescription drugs, including those paid before a beneficiary meets the annual deductible (MRC, 2025i)
• some drug costs covered on behalf of a beneficiary, such as through Employer Group Waiver Plans (CMS, 2024a) and the Part D Extra Help program, State Pharmaceutical Assistance Programs, AIDS Drug Assistance Programs, and Indian Health Service (MRC, 2025i)
• costs reimbursed by other insurance (MRC, 2025i)
• amounts paid by other individuals (including family members) and by most charitable organizations on behalf of the beneficiary (MRC, 2025i)

In contrast, the $2,100 threshold excludes the following expenses:

• monthly premiums
• drugs not covered by the Part D or MA plan
• drugs covered by Medicare Part B (Ayeh, 2025)

During the initial coverage period, pharmaceutical manufacturers provide a discount of 10 percent on certain brand-name drugs, biologics, and biosimilars (Cubanski, 2025a). These discounts also do not count toward the $2,100 OOP cap (CMS, 2024a).

Catastrophic Coverage Period

After reaching the $2,100 OOP threshold, the beneficiary does not have to pay for covered drugs for the remainder of 2026 (CMS, n.d.-l). Premium payments, if applicable, continue throughout the year.

Monthly Prescription Payment Plan

For the second consecutive year, a Medicare Prescription Payment Plan (M3P) will be available to beneficiaries enrolled in any Part D plan or in any other Medicare plan that offers prescription drug coverage (such as an MA plan) (CMS, 2025g). M3P enables beneficiaries to spread their OOP drug costs across the year.

When comparing coverage options using the Medicare Plan Finder (https://www.medicare.gov/plan-compare), beneficiaries and other users can compare estimated prescription drug costs with and without the M3P option. However, each beneficiary must contact their Part D or other health plan directly to sign up for M3P. Beneficiaries can sign up for M3P during the AEP or any time during 2026; likewise, they may withdraw from M3P at any time. M3P is most likely to help beneficiaries who have high prescription drug costs that are not consistent during the year, especially if those costs are incurred during the first nine months of 2026 (CMS, 2025g; Nethery, 2024). Visit https://www.ncoa.org/article/what-is-the-medicare-prescription-payment-plan/ for a four-step process to calculate the potential benefit of M3P enrollment. (Note: Readers will need to update the $2,000 OOP maximum listed in this article to the 2026 level of $2,100 for accurate calculations.)

Any beneficiary who opts in to M3P will receive monthly bills from their drug plan. There is no fee to enroll in M3P, nor does enrollment reduce overall drug costs.

Beneficiaries who participated in M3P in 2025 will be reenrolled automatically as long as they remain in the same Part D or MA plan (Pugh, 2025a). Beneficiaries who are reenrolled automatically in M3P but who wish to opt out must contact their plan to make the change (Pugh, 2025a). Similarly, beneficiaries who change Part D or MA plans but who wish to continue in M3P must contact their new plan to reenroll (Pugh, 2025a).

Decreased Costs for Price-Negotiated Drugs

M3P and the annual spending cap were implemented in 2025 as a result of the Inflation Reduction Act of 2022 (P.L. 117-169). Another provision of the law is the Medicare Drug Price Negotiation Program. This program enables the Secretary of the U.S. Department of Health and Human Services (HHS) to negotiate directly with pharmaceutical manufacturers the prices Medicare will pay for medications, rather than relying on higher commercial prices negotiated by pharmacy benefit managers and health insurers (Martin, 2025). This price negotiation not only reduces OOP prescription drug costs for Medicare beneficiaries but also extends the longevity of the Medicare program. As Senator Bernie Sanders (I-VT) explained in 2021,

Medicare pays far more for drugs than government programs that negotiate. Under current law, the Secretary of the Department of Health and Human Services (HHS) is prohibited from negotiating lower drug prices on behalf of Medicare Part D beneficiaries. In contrast, other government programs, like Medicaid and the Department of Veterans Affairs (VA), are allowed to negotiate. … Medicare paid twice as much for the same prescription drugs as VA in 2017 [and] … Medicare pays nearly three times more than Medicaid for top-selling brand name drugs, on average. (Sanders, 2021, p. 1)

As specified in the Inflation Reduction Act of 2022 (P.L. 117-169), prescription drugs eligible for negotiation must be brand name (not generic), on the market for several years without competition, among the most expensive drugs covered by Medicare, and among those most commonly used by beneficiaries (CMS, n.d.-p, 2024b; Cubanski & Neuman, 2025). 2026 is the first year in which Medicare beneficiaries will pay lower prices for medications as a result of the Medicare Drug Price Negotiation Program, saving from 38 to 79 percent on each of the following drugs:

1. Eliquis
2. Enforel
3. Entresto
4. Farsiga
5. Fiasp/NovoLog
6. Imbruvica
7. Januvia
8. Jardiance
9. Stelara
10. Xarelto (CMS, n.d.-p, 2024b)

These drugs, which will be offered by every Part D plan in 2026, are used to treat conditions such as blood cancers; Crohn’s disease and ulcerative colitis; diabetes and chronic kidney disease; heart failure and blood clots; and psoriasis, psoriatic arthritis, and rheumatoid arthritis (CMS, n.d.-p, 2024b).

Retail discounts on the 10 drugs range from 38 to 79 percent off the 2023 list prices (CMS, n.d.-p, 2024b). A chart published by AARP details the 2023 and 2026 prices for each of the 10 prescription drugs (Pugh, 2025b). These discounted prices will be available to all medically eligible beneficiaries through any MA plan with prescription drug coverage or any Part D stand-alone PDP in 2026 (Cubanski, 2025b; Pugh, 2025b). This universality notwithstanding, the exact decrease in OOP costs for the discounted drugs will vary among beneficiaries, as explained by KFF:

Whether Part D enrollees pay lower out-of-pocket costs for a given Part D selected drug will depend in part on whether they pay flat copayment amounts or a coinsurance rate for the drug in their chosen Part D plan. If they pay coinsurance, they could see savings, assuming the negotiated maximum fair price is lower than their plan’s negotiated price. (Cubanski, 2025b, “How will people with Medicare benefit” section, para. 2)

Collectively, the Medicare Drug Price Negotiation Program has been estimated to reduce beneficiaries’ OOP prescription drug costs by $1.5 billion while yielding $6 billion in savings for the Medicare program in 2026 alone (CMS, n.d.-p). Moreover, negotiated prices will apply to these 10 drugs as long as they remain in the program, with updated prices being posted by CMS each year (Pugh, 2025b); the intent of the Medicare Drug Price Negotiation Program, as established by the Inflation Reduction Act of 2022 (P.L. 117-169), is for the number of discounted medications to accumulate annually (Carter, 2025).

Visit the following links for additional information about the implementation of the Medicare Drug Price Negotiation Program in 2026:

• beneficiary-friendly infographic, including the 10 prescription drugs that will be available at lower cost in 2026: https://www.cms.gov/files/document/infographic-negotiated-prices-maximum-fair-prices.pdf
• detailed fact sheet, including detailed financial information about the discounted drugs for 2026: https://www.cms.gov/files/document/fact-sheet-negotiated-prices-initial-price-applicability-year-2026.pdf
• beneficiary-friendly table, published by AARP, with costs of the 10 drugs for 2026: https://datawrapper.dwcdn.net/Ct4pb/6/#embed

HHS has been negotiating prices throughout 2025 for 15 additional prescription drugs, which will be available to Medicare beneficiaries at discounted prices in 2027; visit https://www.cms.gov/files/document/factsheet-medicare-negotiation-selected-drug-list-ipay-2027.pdf for details. In 2026, HHS will negotiate prices for another 15 prescription drugs, which will include some medications covered by Part B (that is, medications that are usually administered intravenously, in physicians’ officers, or in outpatient centers); beneficiaries will receive discounts for those drugs in 2028 (Pugh, 2025b). Thereafter, HHS will negotiate prices (and beneficiaries will pay lower prices) for 20 additional drugs annually (Martin, 2025).

However, the scope of medications eligible for the Medicare Drug Price Negotiation Program was weakened by the budget reconciliation law (P.L. 119-21) enacted in July 2025 (Carter, 2025). The Congressional Budget Office (CBO) has estimated that the 2025 budget reconciliation act’s changes to the Medicare Drug Price Negotiation Program—changes made by the Republican party at the behest of the pharmaceutical industry (Cubanski & Neuman, 2025)—will cost the federal government $8.8 billion dollars over the next 10 years (Swagel, 2025b). This figure is nearly 10 percent of the overall $98.5 billion CBO had projected price negotiation would save for the Medicare program in its first decade (Cubanski et al., 2023), thereby decreasing sustainability of Medicare as a whole (Cubanski & Neuman, 2025) and increasing OOP costs for Medicare beneficiaries (Carter, 2025).

Visit https://www.medicare.gov/health-drug-plans/part-d/what-drug-plans-cover/how-drug-plans-work to learn more about how Medicare PDPs work.

Continued Reduced-Cost Insulin & Free Vaccines

Reduced-cost insulin—another prescription drug provision of the Inflation Reduction Act of 2022 (P.L. 117-169) that took effect in 2025—remains in effect for 2026 and successive years. Beneficiaries who use insulin products that are covered by Medicare continue to pay no more than $35 per month’s supply of each covered insulin product in 2026; moreover, covered insulin products will not be subject to an annual deductible (CMS, n.d.-m). These benefits apply both to beneficiaries who use insulin products covered by their respective Part D plan and to those who use insulin through a traditional (that is, nondisposable) pump covered under Medicare Part B’s durable medical equipment benefit (CMS, n.d.-m).

Likewise, all vaccines recommended for adults by the federal Advisory Committee on Immunization Practices (ACIP, part of the Centers for Disease Control and Prevention [CDC]; https://www.cdc.gov/acip) will remain available at no cost (including during the deductible phase) to Medicare beneficiaries who are enrolled in Part D or whose MA plan includes prescription drug coverage at no cost, provided the vaccines are administered by a practitioner who accepts Medicare assignment or is in the MA network (CMS, n.d.-k; MRC, 2025h). (Visit https://www.medicare.gov/basics/costs/medicare-costs/provider-accept-Medicare to learn the distinctions among practitioners who accept assignment, those who submit claims to Medicare but are nonparticipating providers, and those who opt out of Medicare.) These include vaccines to prevent the following illnesses:

• respiratory syncytial virus (RSV) (CMS, n.d.-s)
• shingles (CMS, n.d.-t)
• tetanus, diphtheria, and pertussis (whooping cough, commonly known as “Tdap”) (CMS, n.d.-v)

Furthermore, Medicare Part B and MA plans continue to cover the following preventive vaccines at no cost, provided the administering practitioner accepts Medicare assignment or is in the plan network:

• Hepatitis B if the beneficiary is at medium or high risk (CMS, n.d.-f; MRC, 2025d)
• influenza (flu) (CMS, n.d.-e; MRC, 2025c)
• pneumococcal (pneumonia) (CMS, n.d.-q; MRC, 2025j)
• SARS-CoV-2 (COVID-19)—specifically, the 2024–2025 formulas manufactured by Pfizer–BioNTech, Moderna, and Novavax (CMS, n.d.-d; MRC, 2025a)

At the time of this Tips & Tools publication, coverage under original Medicare and MA for the vaccines listed here had not been affected by the Trump administration’s recent changes to HHS, the CDC, or ACIP. Please visit https://www.cdc.gov/acip/vaccine-recommendations/index.html or contact Medicare directly for information regarding the committee’s recommendations for, and Medicare coverage of, other vaccines.

Coverage of COVID-19 Tests & Treatments: A Mixed Bag

Medicare Part B continues to cover the following tests related to COVID-19, usually at no charge to the beneficiary, provided that a health care provider orders the tests and the beneficiary obtains them from a laboratory (including at a clinic, pharmacy, or health care provider’s office) or hospital that accepts Medicare assignment.

• FDA-authorized antibody tests to assess immunity for COVID-19 (CMS, n.d.-a)
• laboratory tests to diagnose or aid in the diagnosis of COVID-19 (CMS, n.d.-b)
• “some tests for related respiratory conditions to aid diagnosis of COVID-19 done together with the COVID-19 test” (CMS, n.d.-b)

CMS (n.d.-b) has encouraged any beneficiary enrolled in MA to check with their plan regarding coverage of the preceding tests.

Similarly, Medicare Part B continues to cover (usually at no cost) FDA-authorized or -approved COVID-19 monoclonal antibody treatments and products, when ordered by a health care practitioner and administered by a provider or supplier who accepts Medicare assignment (CMS, n.d.-c). CMS (n.d.-c) has encouraged beneficiaries enrolled in MA to check with the plan regarding coverage of this treatment.

On the other hand, access to the antiviral treatment Paxlovid will be more limited for Medicare beneficiaries in 2026. Until February 28, 2025, people enrolled in original Medicare, Medicaid beneficiaries, and uninsured people were able to obtain Paxlovid at no cost through a U.S. Government Patient Assistance Program (USG PAP) operated by Pfizer, drug manufacturer (Champions for Vaccine Education, Equity and Progress [CVEEP], n.d.; Sherrell, 2025). However, a consumer-facing website of Pfizer and four other pharmaceutical companies explains,

As of March 1, 2025, … USG PAP no longer covers the full cost of Paxlovid for all Medicare patients. The program will continue to cover certain Medicare patients facing high co-pays.

The program now includes income eligibility criteria and patients with Medicare and Medicaid should check their plans for Paxlovid coverage. (CVEEP, “For Paxlovid” section)

Likewise, people enrolled in MA plans may qualify for a Paxlovid Co-Pay Savings Card (CVEEP, n.d.; personal communication with Maria, PAXCESS Patient Support Program, November 7, 2025). According to staff of the PAXCESS™ Patient Support Program (Maria, personal communication, November 7, 2025), as of early November information had not been provided regarding continuation of the USG PAP and Co-Pay Savings Card for Paxlovid in 2026. Beneficiaries who need this medication or other treatments for COVID-19 in 2026 will need to check with their Part D or MA plan for coverage information.

Varied Coverage of PrEP for HIV Prevention

Medicare coverage of PrEP for HIV prevention will also vary in 2026. Part B will continue to cover oral or injectable antiretroviral drugs for HIV prevention (PrEP), as approved by the U.S. Food and Drug Administration (FDA), at no OOP cost (including during the deductible phase) if the prescribing health care practitioner determines a beneficiary has a high risk of acquiring HIV and the medication is administered in the office of a practitioner who accepts Medicare assignment or obtained through a pharmacy enrolled in Part B (CMS, n.d.-r, 2024c). Likewise, Part B will continue to cover the following related services for beneficiaries who use PrEP for HIV prevention:

• up to eight individual counseling sessions every 12 months
• up to eight HIV screenings every 12 month
• a single screening for Hepatitis B virus (HBV) (CMS, n.d.-t, 2024c)

Please refer to NASW’s Tips & Tools addressing Medicare annual enrollment for 2025 (Herman, 2024) for details regarding Medicare Part B coverage of PrEP and related services. Visit https://www.cms.gov/files/document/prep-hiv-prevention.pdf for a beneficiary-oriented fact sheet about Medicare Part B coverage of PrEP for HIV prevention (and coverage of related services).

In contrast, MA coverage of PrEP for HIV prevention and related services may be more limited in 2026 than it was in 2025. For 2025, MA coverage has matched that of Medicare Part B if the beneficiary were to receive the medication in a health care practitioner’s office or at a pharmacy within the MA plan’s provider network (CMS, 2024c). In 2026, however, coverage of PrEP for HIV prevention and related services will be at the discretion of each MA plan (personal communication with Donshay, 1-800-MEDICARE, November 7, 2025; personal communication with Peggy, Ohio Senior Health Insurance Information Program, November 7, 2025).

An important distinction remains for beneficiaries living with HIV who are enrolled in original Medicare: Part D—not Part B—continues to cover FDA-approved antiretroviral medication as HIV treatments (CMS, 2024c). Any MA beneficiary who uses PrEP for HIV treatment needs to check with their plan regarding coverage.

Screening for HIV, HBV, & Hepatitis C

Any Medicare beneficiary enrolled in Part B who does not use PrEP for HIV prevention and is between the ages of 15 and 65 may continue to receive HIV screening at no cost once a year (or three times during a pregnancy), regardless of risk factors (CMS, n.d.-j). Conversely, HIV screening for beneficiaries younger than 15 or older than 65 is only available if a beneficiary is “at an increased risk for HIV” (CMS, n.d.-j, Who’s eligible section). For beneficiaries enrolled in MA, however, coverage of HIV screening is at the discretion of the plan (personal communication with Donshay, 1-800-MEDICARE, November 7, 2025; personal communication with Peggy, Ohio Senior Health Insurance Information Program, November 7, 2025).

Coverage of screenings for HBV and Hepatitis C will remain consistent in 2026: Medicare Part B will continue to cover screenings for any beneficiary at high risk for one or both of these conditions, provided the screening is ordered by a health care practitioner and the administering practitioner accepts Medicare assignment (CMS, n.d.-h, n.d.-i). These screenings will also be covered by MA plans, provided the screening practitioner is in the plan network (MRC, 2025e, 2025k).

Assistance with OOP Health Costs

Various public programs exist to help beneficiaries who have limited income and resources cover OOP health costs. Eligibility information in this section may be incomplete, and online information may not be accurate for 2026, because Federal Poverty Level (FPL) guidelines for 2026 had not been announced at the time of this Tips & Tools publication. These guidelines will be updated in January; please visit https://aspe.hhs.gov/topics/poverty-economic-mobility/poverty-guidelines for updates.

Medicare Savings Programs (MSPs)

Four MSPs help beneficiaries with original Medicare pay for OOP costs associated with Part A and Part B:

• Qualified Medicare Beneficiary (QMB)
• Specified Low-Income Medicare Beneficiary (SLMB)
• Qualifying Individual (QI)
• Qualified Disabled Working Individual (QDWI)

MSPs are available to beneficiaries who live in the District of Columbia and all 50 states. Names for each program may vary by state (National Council on Aging [NCOA], 2025b). Costs covered by MSPs may include premiums, deductibles, copayments, coinsurance, or some combination of these (CMS, n.d.-n). Eligibility is based on the federal poverty level (FPL) guidelines and financial resources (assets), but variation exists. For example, some states have higher income thresholds; others have higher resource limits or have eliminated asset limits (CMS, n.d.-n; Gershon, 2025; NCOA, 2025a).

Eligibility determination for, and enrollment in, MSPs is often laborious for beneficiaries and redundant for both beneficiaries and service systems. Consequently, MSPs have long been underutilized (Florez et al., 2025; Gershon, 2025; Lipschutz, 2025a; Schwarz, 2025a). The Biden–Harris administration attempted to simplify these processes by finalizing the Streamlining Medicare Savings Program Eligibility Determination and Enrollment Rule (hereafter, “MSP streamlining rule”) in 2023. CMS (2023) estimated that 860,000 beneficiaries would enroll in MSPs for the first time as a result of the rule.

Provisions of the MSP streamlining rule had been rolling out gradually, with final implementation scheduled for April 2026 (Carter, 2023). However, the July 2025 budget reconciliation act (P.L. 119-21) undermined that progress by prohibiting HHS from implementing most of the rule until October 1, 2034 (KFF, 2025). This prohibition does not apply to provisions that had already been implemented, such as autoenrollment of certain SSI beneficiaries into the QMB program (Gershon, 2025; Herman, 2025). Nonetheless, CBO has estimated that the delay will cause almost 1.4 million Medicare beneficiaries to lose access to MSPs (Swagel, 2025a). (Please refer to Gershon, 2025, for a detailed explanation of the MSP streamlining rule and the impact of the 2025 budget reconciliation law.)

Given the delayed implementation of the MSP streamlining rule, education of Medicare beneficiaries about MSPs is especially crucial. Visit one of these webpages for details about program benefits and eligibility:

• CMS: https://www.medicare.gov/basics/costs/help/medicare-savings-programs#collapse-2625
• NCOA: https://www.ncoa.org/article/medicare-savings-programs-eligibility-coverage/ and https://www.ncoa.org/article/medicaid-msp-enrollment/

According to the CMS MSP webpage, a beneficiary “may still qualify for these programs in your state even if your income or resources are higher than the federal limits listed” (CMS, n.d.-n, “How to qualify” section).

Three publicly funded entities offer free, confidential screening for MSP eligibility and can assist beneficiaries in applying for an MSP:

• Medicaid offices—available in every state and the District of Columbia https://www.medicaid.gov/about-us/where-can-people-get-help medicaid-chip#statemenu
• State Health Insurance Assistance Program (SHIP) sites—available in every state and the District of Columbia; additional information is available in Part 2 of this Tips & Tools series, “Navigating Medicare Annual Enrollment for 2026”
• Benefits Enrollment Centers (BECs)—87 sites spread across 38 states; operated by NCOA with a combination of public and private funding (NCOA, 2024) https://www.ncoa.org/article/what-are-becs/

Another helpful resource for Medicare beneficiaries with limited incomes and resources is BenefitsCheckUp^® (https://benefitscheckup.org/ and 1-800-794-6559). Operated by NCOA with public and private funding, BenefitsCheckUp^® is a free and confidential online tool to help beneficiaries determine their eligibility for MSPs and other public programs.

Extra Help for Part D OOP Costs

The Extra Help program—also known as the Low-Income Subsidy (LIS) covers the following Part D OOP costs for eligible enrollees who live in the District of Columbia or 50 states:

• annual deductible (CMS, n.d.-g)
• monthly premiums, up to a state-specific benchmark amount (MRC, 2025b); visit https://www.cms.gov/files/document/regional-rates-and-benchmarks-2026.pdf (p. 2) to find the amounts for 2026
• cost sharing for prescription drugs when an LIS enrollee purchases those drugs in a plan’s participating pharmacy (CMS, n.d.-g)

Cost sharing varies based on multiple factors: FPL and financial resources; enrollment in Medicaid, QMB, SLMB, QI, or SSI; and use of Medicaid home- and community-based services (HCBS) or nursing facility services.) For generic drugs, beneficiaries enrolled in LIS will pay $0, $1.60, or $5.10 per prescription in 2026; for brand-name drugs, those cost sharing will be $0, $4.90, or $12.65 per prescription (Shapiro, 2025, p. 4).

After an LIS enrollee reaches the catastrophic coverage period, they will have no OOP costs for the remainder of the year (CMS, n.d.-g).

The following groups of Medicare beneficiaries qualify automatically for Extra Help:

• beneficiaries with full Medicaid coverage
• beneficiaries who receive Supplemental Security Income (SSI) benefits (CMS, n.d.-g)

A Medicare beneficiary who does not meet one of the three preceding conditions may still qualify for LIS if they meet the following requirements. First, the beneficiary must have an income of 150 percent or less of FPL, with slightly higher limits for Alaska and Hawaii (CMS, n.d.-g). (Visit https://aspe.hhs.gov/sites/default/files/documents/dd73d4f00d8a819d10b2fdb70d254f7b/detailed-guidelines-2025.pdf for an example of FPL guidelines by percentage, although this table has not been updated for 2026.) Second, the beneficiary’s statutory resources (assets) must not exceed the following limits in 2026:

• individual: $16,590 without burial expenses (or related expenses, as described in 20 C.F.R. § 416.1231); $18,090 with burial expenses
• married couple: $33,100 without burial expenses; $36,100 with burial expenses (Shapiro, 2025, p. 3)

Some states may not count certain types of income and assets toward LIS limits, however (MRC, 2025b). When in doubt, beneficiaries should seek assistance from the Social Security Administration, which administers the Extra Help program; visit https://www.ssa.gov/medicare/part-d-extra-help for information, including the option of scheduling a phone appointment to complete an LIS application. (The summary resource list at the end of this publication includes phone and TTY numbers, long with a weblink to find local offices.) Other sources of information regarding Extra Help include SHIP, BECs, and BenefitsCheckUp^®.

At the time of this Tips & Tools publication, one CMS website stated:

Extra Help isn't available in Puerto Rico, the U.S. Virgin Islands, Guam, the Northern Mariana Islands, or American Samoa. But there are other programs available in those areas to help people with limited income and resources. Programs vary in these areas. Call your State Medical Assistance (Medicaid) office [https://www.medicaid.gov/about-us/beneficiary-resources/index.html#statemenu] to learn more. (CMS, n.d.-g)

Limited Income Newly Eligible Transition (LI NET) Program

The Medicare LI NET (or “LINET”) Program provides temporary prescription drug coverage for certain Medicare beneficiaries with low incomes who are not enrolled in a Medicare drug plan (CMS, 2024d). LI NET applies to all Part D–covered drugs purchased at any pharmacy (CMS, 2024d). Such coverage may be retroactive, immediate, or both (CMS, 2024d). Visit the following links for more information about LI NET eligibility and coverage:

• CMS LI NET page (with links to multiple resources; information for 2026 had not been posted at the time of this Tips & Tools publication) https://www.cms.gov/medicare/enrollment-renewal/part-d-plans/low-income-subsidy/medicare-limited-income-net-program
• Four-page tip sheet for service providers (last updated in August 2024): https://www.cms.gov/files/document/li-net-retroactive-coverage-tip-sheet.pdf

State Pharmaceutical Assistance Programs (SPAPs)

SPAPs help people pay for prescription drugs. SPAP eligibility and benefits vary, even among those that work with Medicare Part D (MRC, 2025l). At the time of this Tips & Tools publication, 43 states, the District of Columbia, and Puerto Rico had SPAPs, according to CMS.

• Search for an SPAP: https://www.medicare.gov/plan-compare/#/pharmaceutical-assistance-program/states?year=2025&lang=en
• Questions to ask when considering SPAP enrollment: https://www.medicareinteractive.org/understanding-medicare/cost-saving-programs/state-pharmaceutical-assistance-programs-spaps/questions-to-ask-when-considering-an-spap

AIDS Drug Assistance Program (ADAP)

Funded by the Ryan White Act and administered by the federal Health Resources and Services Administration (HRSA), ADAP provides FDA-approved medications to people living with HIV who have low incomes and are uninsured or underinsured (HRSA, 2024). ADAP funds may also be used to purchase health insurance for eligible clients and to provide services that improve HIV medication access, adherence, and monitoring (HRSA, 2024).

ADAP serves all 50 states, the District of Columbia, American Samoa, Federated States of Micronesia, Guam, Marshall Islands, Northern Mariana Islands, Palau, Puerto Rico, and the U.S. Virgin Islands (HRSA, 2024). (Note: Most residents of Program benefits and eligibility may vary by location (HRSA, 2024). Visit https://adap.directory/directory to find an ADAP site.

Private Programs to Reduce OOP Health Costs

Although this publication focuses on government-funded programs, some private programs may be of use to Medicare beneficiaries.

• CMS hosts an online database of private pharmaceutical assistance programs (also known as patient assistance programs) for Medicare beneficiaries enrolled in a Part D PDP. Visit https://www.medicare.gov/plan-compare/#/pharmaceutical-assistance-program?year=2026&lang=en to search for a program by medication name.
• Some prescription discount cards offer reduced prices for numerous medications at a multitude of pharmacies. However, CMA has cautioned, such cards cannot be combined with Medicare Part D and are not counted toward the OOP spending cap (Lipschutz et al., 2025).
• Some national nonprofit organizations offer their own financial assistance programs. Example include the Patient Access Network (PAN) Foundation, which enables users to search its Fund Finder by medication or health condition (https://www.panfoundation.org/find-disease-fund/), and the National Organization for Rare Disorders (NORD), which connects users with premium and copay support, other medical assistance, an emergency relief program, and clinical trial support (https://rarediseases.org/patient-assistance-programs/financial-assistance/).
• Other sources worth checking for assistance with OOP health costs include nonprofit organizations (whether local or national) and foundations focused on specific health conditions.

These private programs may be valuable resources for some Medicare beneficiaries. However, each beneficiary needs to compare OOP prescription costs under these programs with their original Medicare or MA coverage to ensure they receive the most comprehensive coverage available.

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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.

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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

• English https://www.cms.gov/outreach-and-education/reach-out/find-tools-to-help-you-help-others/open-enrollment-outreach-and-media-materials
• Spanish https://www.cms.gov/outreach-and-education/reach-out/find-tools-to-help-you-help-others/open-enrollment-materials-for-spanish-speakers
• Content for American Indian & Alaska Native (AI/AN) communities
  In previous years, CMS created public-service announcements (PSAs) for the Medicare AEP in 10 Indigenous languages. The Trump administration has not created these PSAs this year. The administration has retained six English-language fliers that had been designed for AI/AN communities. https://www.cms.gov/Outreach-and-Education/Reach-Out/Find-tools-to-help-you-help-others/Open-Enrollment-materials-for-other-audiences
  To find more Medicare resources for AI/AN communities, visit https://www.cms.gov/training-education/partner-outreach-resources/american-indian-alaska-native/medicare-ia-ans and click on the topics under “Brochures and fact sheets” in the right sidebar. Visit https://www.cms.gov/training-education/partner-outreach-resources/american-indian-alaska-native/outreach-education-resources#outreach for related resources.
• Arabic, Chinese, Creole, Khmer, Korean, Polish, Russian, & Vietnamese
  Written materials had been available in these languages in previous years. The Trump administration has removed this content and has not created new content.

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.