Medicaid
Changes Are Being Discussed Nationally
Federal policymakers continue discussing:
- Medicaid eligibility verification requirements.
- Medicaid funding reforms.
- Work requirements in certain Medicaid programs.
- Increased program integrity measures for ACA Marketplace enrollments.
- Expect additional documentation requirements in some circumstances.
- Renewal assistance will become increasingly important for consumers
Part D
Medicare Part D Changes Continue in 2026
Several Medicare Part D changes that began in 2025 remain in effect:
- The Coverage Gap ("Donut Hole") has been eliminated.
- Annual prescription drug costs are capped.
- Monthly Special Enrollment Periods are available for many Dual Eligible and LIS beneficiaries.
- Plans continue adjusting formularies and pharmacy networks for 2026.
CMS Proposes
Major Medicare Physician Payment Changes
CMS has proposed one of the largest Medicare physician payment reforms in years. The proposal shifts reimbursement toward primary and preventive care while attempting to reduce long-term healthcare costs.
What this means for Medicare beneficiaries:
What this means for Medicare beneficiaries:
- Greater emphasis on preventive services.
- Potential improvements in primary care access.
- Future Medicare Advantage plans may adjust their provider arrangements accordingly.
NYSOH
Essential Plan Changes Coming in July 2026
What New Yorkers Need to Know
New York residents enrolled in the Essential Plan through New York State of Health will see an important change this summer. State officials have confirmed that certain Essential Plan options for individuals earning approximately 200–250% of the federal poverty level will end in July 2026 as part of program updates and eligibility restructuring.
This change means that many current members will no longer qualify for their existing Essential Plan coverage and must take action to avoid a gap in health insurance. Affected individuals will need to update their application and transition to a new plan—most commonly a Qualified Health Plan (QHP) through the Marketplace, often with financial assistance such as premium tax credits to keep coverage affordable.
Health experts stress that members should not wait until the last minute. Reviewing eligibility early and submitting updated information to the Marketplace is critical to ensure continuous coverage beyond July. Missing deadlines could result in temporary loss of benefits, including access to doctor visits, prescriptions, and preventive care.
This change means that many current members will no longer qualify for their existing Essential Plan coverage and must take action to avoid a gap in health insurance. Affected individuals will need to update their application and transition to a new plan—most commonly a Qualified Health Plan (QHP) through the Marketplace, often with financial assistance such as premium tax credits to keep coverage affordable.
Health experts stress that members should not wait until the last minute. Reviewing eligibility early and submitting updated information to the Marketplace is critical to ensure continuous coverage beyond July. Missing deadlines could result in temporary loss of benefits, including access to doctor visits, prescriptions, and preventive care.
Local agencies like Instant Health are stepping in to help community members navigate the transition. Instant Health provides personalized Consultation, support including eligibility reviews, plan comparisons, and full enrollment assistance. Their licensed brokers work one-on-one with clients to ensure they understand their options and secure coverage that fits both their medical needs and budget.
“Our goal is to make this transition simple and stress-free,” said a representative from Instant Health. “We guide our clients every step of the way—from reviewing their current plan to enrolling them in the best available alternative.”
Members currently enrolled in the Essential Plan are encouraged to check their notices, respond to any requests from the Marketplace, and seek professional guidance if needed. With the right support, transitioning coverage can be smooth—and most individuals will still have access to low-cost, comprehensive health insurance options.
For assistance, individuals can contact Instant Health for a free consultation and enrollment support before the July 2026 deadline.
“Our goal is to make this transition simple and stress-free,” said a representative from Instant Health. “We guide our clients every step of the way—from reviewing their current plan to enrolling them in the best available alternative.”
Members currently enrolled in the Essential Plan are encouraged to check their notices, respond to any requests from the Marketplace, and seek professional guidance if needed. With the right support, transitioning coverage can be smooth—and most individuals will still have access to low-cost, comprehensive health insurance options.
For assistance, individuals can contact Instant Health for a free consultation and enrollment support before the July 2026 deadline.
Standalone Medicare
Standalone Medicare Plans to Require Prior Authorization Under New Policy Shift
A new policy change is set to impact millions of Medicare beneficiaries as standalone Medicare coverage begins requiring prior authorization for certain services. The update, guided by the Centers for Medicare & Medicaid Services, is part of a broader effort to control healthcare costs and ensure that treatments meet medical necessity standards.
Traditionally, beneficiaries enrolled in Original Medicare—particularly those using standalone Medicare Part A and Medicare Part B—have had fewer administrative barriers compared to Medicare Advantage plans. However, under the new framework, certain outpatient procedures, diagnostic tests, and specialty services may now require approval before they are performed.
Traditionally, beneficiaries enrolled in Original Medicare—particularly those using standalone Medicare Part A and Medicare Part B—have had fewer administrative barriers compared to Medicare Advantage plans. However, under the new framework, certain outpatient procedures, diagnostic tests, and specialty services may now require approval before they are performed.
Healthcare analysts say the move aims to reduce unnecessary procedures and improve care coordination, but it may also introduce new complexities for patients and providers. Beneficiaries could face delays in receiving care if authorization requests are not submitted correctly or processed in time.
“This is a significant shift for people who chose standalone Medicare specifically for its flexibility,” said industry observers. “Understanding when prior authorization is required will be critical moving forward.”
Patients are advised to work closely with their doctors to ensure all required documentation is submitted in advance. Failing to obtain prior authorization when required could result in denied claims or unexpected out-of-pocket costs.
Organizations like Instant Health are helping beneficiaries adapt to the changes by offering guidance on plan rules, coverage verification, and navigating approvals. Their licensed agents assist clients in understanding how these requirements apply to their specific situation and can help evaluate whether alternative coverage options—such as Medicare Advantage plans—may better suit their needs under the new rules.
As the healthcare landscape continues to evolve, experts recommend that Medicare beneficiaries stay informed, review their coverage annually, and seek professional support to avoid disruptions in care.
“This is a significant shift for people who chose standalone Medicare specifically for its flexibility,” said industry observers. “Understanding when prior authorization is required will be critical moving forward.”
Patients are advised to work closely with their doctors to ensure all required documentation is submitted in advance. Failing to obtain prior authorization when required could result in denied claims or unexpected out-of-pocket costs.
Organizations like Instant Health are helping beneficiaries adapt to the changes by offering guidance on plan rules, coverage verification, and navigating approvals. Their licensed agents assist clients in understanding how these requirements apply to their specific situation and can help evaluate whether alternative coverage options—such as Medicare Advantage plans—may better suit their needs under the new rules.
As the healthcare landscape continues to evolve, experts recommend that Medicare beneficiaries stay informed, review their coverage annually, and seek professional support to avoid disruptions in care.
Marketplace Subsidies Shift in 2026
What to Know About Advance Premium Tax Credits
Major changes are reshaping financial assistance for health insurance in 2026, affecting millions of Americans who rely on Marketplace coverage through the Affordable Care Act (ACA).
Advance Premium Tax Credits (APTC)—the subsidies that help lower monthly premiums—are still available in 2026, but the level of financial help has decreased following the expiration of enhanced tax credits at the end of 2025
Advance Premium Tax Credits (APTC)—the subsidies that help lower monthly premiums—are still available in 2026, but the level of financial help has decreased following the expiration of enhanced tax credits at the end of 2025
The enhanced subsidies, originally introduced during the COVID-19 pandemic, had significantly reduced costs and expanded eligibility. Without them, many consumers are now facing higher monthly premiums and reduced financial support.
According to recent analysis, Marketplace premiums after subsidies have risen sharply for many enrollees. Some consumers are seeing average premium payments more than double compared to prior years, while overall enrollment has already declined as affordability becomes a growing concern.
At the same time, eligibility rules have tightened. In 2026, subsidies generally return to pre-pandemic guidelines, meaning individuals with incomes above 400% of the federal poverty level may no longer qualify for financial assistance.
Another major change impacts tax season: starting with the 2026 tax year, there are no longer caps on repayment of excess APTC. If a consumer underestimates their income, they may be required to pay back the full amount of subsidy they received when filing taxes in 2027.
Despite these changes, federal officials note that many individuals will still qualify for some level of assistance, and a range of plans remain available. In fact, a portion of enrollees can still find low-cost plans depending on income and eligibility.
Healthcare experts emphasize that consumers should actively review and update their Marketplace applications, especially income and household information, to avoid unexpected costs or repayment obligations.
According to recent analysis, Marketplace premiums after subsidies have risen sharply for many enrollees. Some consumers are seeing average premium payments more than double compared to prior years, while overall enrollment has already declined as affordability becomes a growing concern.
At the same time, eligibility rules have tightened. In 2026, subsidies generally return to pre-pandemic guidelines, meaning individuals with incomes above 400% of the federal poverty level may no longer qualify for financial assistance.
Another major change impacts tax season: starting with the 2026 tax year, there are no longer caps on repayment of excess APTC. If a consumer underestimates their income, they may be required to pay back the full amount of subsidy they received when filing taxes in 2027.
Despite these changes, federal officials note that many individuals will still qualify for some level of assistance, and a range of plans remain available. In fact, a portion of enrollees can still find low-cost plans depending on income and eligibility.
Healthcare experts emphasize that consumers should actively review and update their Marketplace applications, especially income and household information, to avoid unexpected costs or repayment obligations.