Medicare is experiencing significant upheaval, with a mix of beneficial reforms and concerning policy shifts unfolding between now and 2028. While some changes promise to reduce costs and expand access, others threaten to limit care options or reduce transparency. These 10 changes will reshape how Medicare works.
Out-Of-Pocket Drug Costs May Be Capped At $2,000
Since the start of 2025, Medicare Part D has capped annual out-of-pocket spending at $2,000. This reform, created under the Inflation Reduction Act of 2022 and confirmed by CMS in late 2023, simplifies costs and makes prescription drug spending predictable.
Medicare May Begin Negotiating Drug Prices
This change could help lower what people pay each month and reduce the amount the government spends. Starting in 2026, Medicare plans to negotiate prices on 10 expensive drugs, including Eliquis and Imbruvica. By 2027, 15 additional drugs will follow, with penalties for manufacturers who fail to comply.
Inpatient Admission Decisions Will Be Locked In
Medicare Advantage plans will lose the ability to reverse approved inpatient admissions beginning in 2026, except for fraud or clear errors. Patients gain protection from surprise bills and appeals, while doctors gain confidence that their hospital care decisions will remain secure after discharge.
Preventive Heart Screenings May Be Reimbursed
Heart health might get a helpful boost. Medicare could start covering preventive tests, such as blood pressure and cholesterol checks, based on national guidelines. The idea is to catch early warning signs, which may help patients sidestep strokes and heart attacks before they become serious problems.
Dental Coverage May Expand For Chronic Conditions
The government may begin offering dental coverage through Medicare for individuals with severe medical conditions, such as kidney failure. Those undergoing dialysis would likely be at the front of the line. It’s also reviewing support for other chronic illnesses, but only when the dental work directly supports medical treatment.
AI-Assisted Prior Authorizations May Be Piloted
Obtaining treatment approvals can take too long, but a new pilot project aims to address this issue. Starting in 2026, it will run in Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington. Artificial intelligence will help doctors speed approvals for necessary care.
Medicare Advantage Enrollment May Reach Around 55%
Medicare Advantage plans are growing rapidly because they combine multiple benefits under one roof and often prove more cost-effective. By 2028, projections suggest enrollment will fall between 51% and 59% of Medicare users. Longer-term estimates reach 64% by 2034.
Medicaid Cuts May Impact Rural Medicare Access
Big changes in Medicaid could quietly hurt Medicare access in rural towns. If hospital funding were to drop, as proposed, services may shrink. In Maine, nearly half of rural hospitals face the risk of closure. A new law might also reduce Medicare’s hospital budget by 4%, further worsening access.
Marketing Rules For Medicare Advantage May Be Relaxed
The Centers for Medicare & Medicaid Services (CMS) is now considering easing rules on advertisements and the information that brokers must disclose to consumers. Critics argue that this might confuse seniors or obscure important differences. Brokers may not need to show side-by-side comparisons, which raises fresh concerns about fairness and transparency.
Biosimilar Substitutions May Accelerate
Medicare Part D plans may soon switch to biosimilars more quickly, even without pre-approval. The move could cut the cost of pricey treatments like arthritis injections and insulin. CMS would still keep a close eye on the process to make sure patients stay safe every step of the way.
