Millions of UnitedHealthcare Medicare Advantage members are facing new rules and stricter requirements starting this year. The changes affect how members see doctors, access benefits, and pay for prescriptions.
The biggest change: most members must now get a referral before seeing a specialist. This applies to all HMO and HMO-POS plan members and started January 1, 2026.
UnitedHealthcare says the move is necessary for “plan sustainability” after federal pilot programs ended. But many members say they were caught off guard by the sudden shift.
Referral Requirement Now in Effect
Starting this month, members need approval from their primary care provider before visiting a specialist for office visits or outpatient services. Members who skip this step could face claim denials starting May 1, 2026.
UnitedHealthcare is offering a grace period through April 30. During this time, claims will not be rejected for missing referrals. But after that, members will be responsible for the full cost if they don’t follow the rules.
Some services are exempt. Members do not need referrals to see:
- Mental health providers
- OB/GYNs
- Chiropractors
- Audiologists
- Oncologists
Chronic Condition Verification for Food and Utility Benefits
UnitedHealthcare also changed access to supplemental benefits like healthy food and utility assistance. Members must now have a verified chronic condition such as diabetes, high blood pressure, or heart disease to use UCard credits for these items.
This change follows the end of the federal Value-Based Insurance Design (VBID) program. The program allowed broader access to non-medical benefits without health qualifications.
Over-the-counter products are still available to all members without condition verification, according to UnitedHealthcare.
600,000 Members Lost Coverage
UnitedHealthcare discontinued more than 100 plans and exited 16 counties for 2026. Roughly 600,000 members were affected nationwide.
Members received non-renewal notices in October 2025. Those who did not choose a new plan by December 31 were automatically moved to Original Medicare on January 1.
However, affected members have until February 28, 2026, to enroll in a new Medicare Advantage plan under a Special Election Period.
Prescription Drug Costs Rise
Drug costs are also changing. The annual out-of-pocket maximum for Part D prescription drugs increased to $2,100 in 2026, up from $2,000 last year.
Insulin costs remain capped at $35 per month. Additionally, the first round of Medicare-negotiated prices for 10 high-cost drugs—including treatments for diabetes and blood clots—takes effect this year, according to the Centers for Medicare & Medicaid Services (CMS).
What Members Should Do Now
UnitedHealthcare urges members to:
- Confirm their plan type (HMO, HMO-POS, or PPO)
- Contact their primary care provider to request referrals before scheduling specialist appointments
- Verify eligibility for supplemental benefits through their UCard portal
- Review their prescription drug coverage and costs for 2026
Members with questions can call the number on the back of their insurance card or visit Medicare.gov for assistance.
The changes are part of a broader shift in Medicare Advantage as insurers adjust to reduced federal funding and tighter regulations.
