Medicare Advantage Enrollment 2026: Expert Analysis | Mark Meiselbach, PhD

Nearly three million Americans enrolled in Medicare Advantage plans could face coverage disruptions in 2026, as a confluence of policy changes and market dynamics reshapes the landscape of this increasingly popular health insurance option. The anticipated shifts, detailed in recent analysis by health policy expert Mark Meiselbach, PhD, signal a potential reckoning for Medicare Advantage (MA), a program that now covers over half of all Medicare beneficiaries.

The Looming Changes in Medicare Advantage

Medicare Advantage plans, offered by private insurers, have grown significantly in recent years, attracting beneficiaries with features like lower cost-sharing and supplemental benefits – often including vision, dental, and hearing coverage. However, a shift in how the Centers for Medicare & Medicaid Services (CMS) calculates risk adjustment, coupled with the phasing out of a temporary increase in MA payments, is expected to reduce plan profitability. This, in turn, is prompting some insurers to exit certain markets, particularly rural areas, or to significantly alter their plan offerings. As Dr. Meiselbach explains, these changes are likely to lead to forced disenrollments for a substantial number of beneficiaries.

The core of the issue lies in the risk adjustment system. This system aims to compensate MA plans for enrolling sicker individuals who require more expensive care. Recent changes are designed to more accurately reflect the actual health status of enrollees, but they as well mean that plans will receive less funding for some beneficiaries. Simultaneously, a temporary increase in MA payments, introduced during the pandemic, is set to expire, further squeezing plan margins.

Who Will Be Most Affected?

The impact of these changes won’t be felt equally across the country. Rural areas are particularly vulnerable, as insurers may uncover it less profitable to operate in these markets due to lower enrollment densities and higher healthcare costs. This could exacerbate existing disparities in access to care for rural Medicare beneficiaries. Dr. Meiselbach’s research suggests that beneficiaries with lower incomes and those in poorer health are also at higher risk of being affected. Research published in JAMA Network, co-authored by Meiselbach, further details the potential for forced disenrollments following plan exits.

It’s important to understand what “forced disenrollment” means. It doesn’t mean beneficiaries will lose Medicare coverage entirely. Rather, it means they will be automatically assigned to Original Medicare – the traditional fee-for-service Medicare program – if their current MA plan ceases to operate in their area or if their specific plan is discontinued. While Original Medicare provides comprehensive coverage, beneficiaries may need to find new providers and adjust to different cost-sharing arrangements.

Understanding Risk Adjustment and Its Implications

Risk adjustment is a complex process. It relies on diagnoses submitted by healthcare providers to estimate the health risk of each enrollee. Plans with sicker populations receive higher payments to reflect their expected costs. The recent changes to the risk adjustment methodology aim to address concerns that plans were “upcoding” – submitting diagnoses that were not entirely accurate to inflate their risk scores and receive higher payments. While increased accuracy is a positive goal, it has unintended consequences for plan finances.

The phasing out of the temporary payment increase, initially implemented to stabilize the MA market during the COVID-19 pandemic, adds another layer of complexity. This increase provided a financial cushion for plans, but its removal will likely put further pressure on profitability, especially for plans operating in less favorable markets.

What Does This Mean for Medicare Beneficiaries?

For beneficiaries currently enrolled in Medicare Advantage, the key takeaway is to be prepared for potential changes. It’s crucial to stay informed about the plans available in their area and to carefully evaluate their options during the annual enrollment period. Beneficiaries should also understand the differences between Medicare Advantage and Original Medicare, including the provider networks, cost-sharing arrangements, and coverage rules. Medicare.gov provides comprehensive information about both options.

Those who are automatically disenrolled from their MA plan will receive a notice from Medicare and will have an opportunity to enroll in a different MA plan or in Original Medicare. It’s important to act promptly to avoid any gaps in coverage.

The Broader Context: Mark Meiselbach’s Research

Mark K. Meiselbach, PhD, is an Assistant Professor at the Johns Hopkins Bloomberg School of Public Health, specializing in privately managed insurance markets, including Medicare Advantage. His research focuses on the factors influencing insurer and employer choices in these markets and the impact of those choices on access to care and financial security for enrollees. He has published extensively on topics related to health economics, labor economics, and managed care, including studies on hospital pricing and access to mental health and substance use disorder treatments. His work provides valuable insights into the complexities of the Medicare Advantage program and the challenges facing beneficiaries.

Examining Hospital Pricing Disparities

Dr. Meiselbach’s research extends beyond enrollment trends. He has also investigated disparities in hospital pricing between commercial plans and Medicare Advantage. His work indicates that hospital prices for commercial plans are often significantly higher than those negotiated by Medicare Advantage plans, even when the same insurer is involved. This highlights the potential for cost savings through Medicare Advantage, but also raises questions about the fairness of pricing practices.

What Comes Next: Monitoring and Potential Adjustments

The CMS is closely monitoring the impact of these changes and is likely to make adjustments as needed. The agency has indicated that it is committed to ensuring that beneficiaries have access to affordable and high-quality care. Ongoing surveillance of MA plan participation rates and beneficiary disenrollment patterns will be crucial. Further research is needed to fully understand the long-term consequences of these policy changes and to identify strategies for mitigating any negative impacts. Beneficiaries should regularly check for updates on Medicare policies and plan offerings through official channels, such as the Medicare website and their local State Health Insurance Assistance Program (SHIP).