Anthem’s Medicare Advantage business is currently navigating one of its most consequential periods in recent memory. With major provider departures, revamped benefit designs, and a significant boost in federal payments, seniors enrolled in or evaluating the insurer’s Medicare plan options face a changing terrain. For those relying on Anthem for Part A, Part B, and Part D coverage — plus supplemental extras — this is a pivotal moment. Understanding the unfolding dynamics could make a difference in health-care access, out-of-pocket spending, and quality of life.
Federal Rate Increases Give Anthem New Leverage
At the heart of recent developments is a meaningful increase in what Medicare is willing to pay the insurer for its Advantage offerings. As of 2026, Anthem stands to receive an approximately 5 percent boost in its MA reimbursement. This renewed financial strength not only helps cover rising medical costs but also positions the company to better negotiate reimbursements with hospitals and physician groups.
In practical terms, this means Anthem may be able to preserve or even expand certain benefits that were under pressure before. Higher government payments could support wider access to care, stronger supplemental services, and resilience amid network tensions.
Provider Network Turbulence: Who’s In, Who’s Out
One of the most urgent concerns for members is the changing provider network. Several high-profile provider systems are exiting or renegotiating contracts, and that has direct consequences for beneficiaries who depend on those providers.
Mount Sinai’s Exit
A major system in New York is set to break ties with Anthem’s MA network. Physicians affiliated with this system will no longer be in network starting January 1, 2026, and the affiliated hospitals and outpatient centers are slated to go out of network as of March 1. For those who routinely use specialists or hospital-based care within this system, the change could bring significantly higher costs. Anthem is offering continuity-of-care options and assistance in finding replacement in-network providers, but beneficiaries will need to assess whether switching plans or providers makes more sense.
MU Health Care Departure
In Missouri, another large health system is leaving Anthem’s Medicare plan network effective April 1, 2025. MU Health Care has cited disagreements over reimbursement rates as the cause, noting that its requested increases were not met. As a result, Anthem members in that region must now decide whether to find new in-network providers, apply for continuity-of-care coverage, or potentially change plans altogether. Anthem has indicated that some continuity-of-care arrangements may be allowed for members with more complex or ongoing treatment needs, but transitions may not be seamless for everyone.
Negotiation Pressure Elsewhere
These two exits are not the only stress points. Anthem is reportedly in detailed contract discussions with other providers across various states. Some systems are pushing back on proposed reimbursement terms; others are seeking stronger alignment on quality-based payment models. For its part, Anthem needs to balance cost containment with network breadth if it wants to remain a compelling choice for Medicare enrollees.
Enhanced Supplemental Benefits: Meeting Social and Chronic Needs
Even as network questions swirl, Anthem is rolling out a richer set of supplemental benefits, especially for chronic-care populations. These enhancements are part of a broader trend in which Medicare plans increasingly offer non-medical supports to help members live healthier, more stable lives.
Monthly Allowances for Dual-Eligibles
In regions where dual-eligible (D-SNP) plans are offered, Anthem is introducing monthly “Everyday Options” allowances. Members can use these funds — via a prepaid card or a similar mechanism — for groceries, utilities, over-the-counter supplies, and other essential items. The goal is to give vulnerable members greater flexibility to spend on things that matter to their day-to-day well-being, not just clinical care.
Transportation and Utility Assistance
Some plans now provide non-emergency transportation to non-clinical destinations, such as grocery stores or community centers. In addition, limited utility support is being made available under certain chronic-care benefit structures — a recognition that social determinants of health (like housing and food security) play a crucial role in overall health outcomes.
Behavioral Health Expansion
Anthem is also investing more in behavioral health. Licensed counselors and marriage-and-family therapists are being added to provider rosters in MA plans, making mental health services more accessible. The company is especially pushing for intensive outpatient programs (IOPs) — a setting that sits between traditional outpatient therapy and full inpatient hospitalization — to give beneficiaries more intermediate-level options for behavioral health care.
Prescription Drug Coverage Reimagined
Prescription medication is often a major cost driver for seniors, and Anthem’s Medicare plan is responding with smarter design changes. Several of its offerings now allow members to pay for their drug costs with a monthly payment option, rather than facing a heavy lump sum payment. This continuity eases cash flow, particularly for those on fixed incomes.
Additionally, many of Anthem’s Part D–equipped plans cap out-of-pocket costs for drugs at a significantly lower threshold than in previous years, offering added financial protection. Members will want to closely review their plan’s formulary, as covered medications and their tier assignments may change annually — particularly for chronic therapies like diabetes or cardiovascular drugs.
Star Ratings, Quality, and Performance Pressures
Quality remains a cornerstone of Medicare Advantage competition. Anthem, like other insurers, is evaluated on CMS star ratings, which assess outcomes such as preventive care, chronic-disease management, and customer experience. These metrics carry real financial weight: higher star ratings translate into bonus payments that support the richness of a plan’s benefits.
For beneficiaries, plan quality is more than a number; it reflects how well their insurer coordinates care, manages chronic illness, and helps them use preventive services. Anthem will likely need to lean into quality improvement initiatives to maintain favorable ratings and justify its network and benefit designs.
Continuity-of-Care: Saving Access for Vulnerable Patients
Anthem is establishing continuity-of-care protocols to shield certain members from abrupt network losses. If a provider is leaving the network, or a hospital system is no longer contracted, members who are already in active treatment or managing complex conditions might be allowed to continue seeing those providers temporarily.
However, the process is not automatic: approval may require documentation, and the duration of continued access will depend on Anthem’s decision-making. For patients who rely on specialized care or have long-term treatment relationships, applying early and working directly with both Anthem and their provider is essential.
Strategic Enrollment Tips for Beneficiaries
With all these changes in motion, it’s more important than ever for seniors to carefully consider their options when enrolling or re-evaluating their plan.
- Check provider directories now: Don’t wait until the last minute. Confirm that your preferred doctors, hospitals, and outpatient centers remain in network for 2026, especially if they’re high-use or specialty providers.
- Read your Annual Notice of Change (ANOC): This document explains changes to benefits, costs, and networks. Compare your old and new plan side by side, and flag any surprising shifts.
- Explore other MA plans or Original Medicare: If network access deteriorates in your Anthem plan, consider switching to another Advantage plan or to Original Medicare. For many, pairing Original Medicare with a Medigap supplement and a standalone Part D plan is a viable alternative.
- Apply for continuity-of-care early: If you rely on a provider who is leaving Anthem’s network, initiate the continuity-of-care process well in advance. Make sure your physician supports your request, and provide any required clinical documentation.
- Talk to a trusted advisor: Engage a licensed Medicare broker, your local State Health Insurance Assistance Program (SHIP), or an independent advocate. They can walk you through benefit comparisons, network risks, and long-term cost implications.
Risks and Challenges on Anthem’s Horizon
While there’s potential upside, Anthem’s MA business is also exposed to significant challenges.
- Provider fragmentation: As systems like Mount Sinai and MU Health Care depart, there’s a risk of shrinking networks, especially in major metropolitan and academic markets.
- Member dissatisfaction: Sudden changes in access or benefits may drive frustration and prompt members to switch plans — threatening retention.
- Regulatory headwinds: As CMS tightens oversight of Medicare Advantage, Anthem could face greater scrutiny around how it prices risk and calibrates its supplemental benefits.
- Financial balancing act: Despite higher Medicare payments, rising medical inflation, increased utilization, and quality-based incentives could squeeze profits unless well managed.
- Communication gaps: Effectively informing thousands of members about network exits, new benefit options, and continuity-of-care processes is a massive challenge — missteps could lead to confusion and lost coverage.
Opportunities for Anthem to Redefine Its Advantage Offering
Against headwinds, there is room for Anthem to reinvent and fortify its Medicare business.
- Prioritize value over volume in contracting: Rather than chasing every hospital, Anthem could focus on strategic partnerships with systems that deliver high-quality, efficient care and collaborate on outcomes-based contracts.
- Deepen supplemental benefits: Expanding allowances, transportation, and social supports further could help Anthem differentiate in the crowded MA marketplace — especially for chronically ill and dual-eligible members.
- Leverage data and care coordination: By using its payment leverage, Anthem can invest in care management programs, predictive analytics, and integrated networks that lower costs and improve patient outcomes.
- Strengthen communication and navigation: Investing in member engagement tools — like mobile apps, outreach teams, and customer-education platforms — can help members understand how their coverage is changing and what they need to do.
- Focus on quality improvement: Advancing preventive care, disease management, and patient experience will not only boost star ratings but also reduce avoidable costs in the long run.
What to Watch in 2026 and Beyond
As Anthem navigates this transitional phase, a few key developments will shape the path ahead:
- Whether the company can reach a new deal with Mount Sinai, allowing reinstatement of in-network relationships or at least locking in better terms.
- How many members successfully obtain continuity-of-care protections during the transition, and how smoothly Anthem manages that process.
- The rollout and uptake of expanded social-benefit allowances and whether they meaningfully improve members’ quality of life and health outcomes.
- Anthem’s performance on CMS star ratings in the next cycle, which will influence not just bonus payments but market competitiveness.
- Growing regulatory scrutiny: how CMS responds to plan design changes, risk-adjustment models, and the use of supplemental funds.
- Competitive moves: how other insurers adapt their Advantage offerings in response and whether Anthem retains or gains market share.
Why This Moment Matters for Seniors
For many Medicare beneficiaries who count on Anthem for their health coverage, the stakes are high. The company’s ability to navigate provider exits, enhance benefits, and maintain quality will determine whether its plans remain viable and attractive.
For dual-eligible members, the new non-medical allowances could offer meaningful support for social needs that affect health. For those with complex or ongoing treatment relationships, continuity-of-care policies may make or break access. Meanwhile, the lowered drug cost caps and payment flexibility could ease financial burden for many enrollees.
But these promises come with caveats. Members must stay vigilant, read their plan materials closely, and take action during enrollment windows. Otherwise, changes in 2026 could bring unwelcome surprises — or worse, loss of access to trusted care.
Bottom Line
Anthem’s Medicare plan business stands at a crossroads — buoyed by stronger federal funding, yet under pressure from major network shakeups. The company is expanding benefits in meaningful ways, but must also contend with provider exits, regulatory risk, and communication challenges. For seniors navigating Anthem’s coverage, it’s a moment to be proactive: verify your doctors, understand your plan’s new benefits, and don’t hesitate to explore alternatives if your access or costs are changing.
If you’re navigating these changes, wondering how your care might be affected, or figuring out whether to switch, drop a comment below or check back as things evolve — your voice matters, and staying informed will serve you well.