For patients managing chronic conditions, the new year often brings a “re-evaluation” of their medical necessity. As of January 2026, insurance carriers are intensifying their coverage reviews targeting long-term patients, particularly those enrolled in Medicare Advantage and employer-sponsored plans. This shift is driven by the expiration of broad pandemic-era waivers and the launch of the CMS ACCESS (Advancing Chronic Care with Effective, Scalable Solutions) Model. Under these 2026 rules, insurers are moving away from “passive renewals” for high-cost chronic treatments, instead requiring frequent “Outcome-Aligned” data to prove that long-term care is still improving or maintaining your health.
The Shift to “Outcome-Aligned” Reviews
The primary reason for coverage reviews long-term patients is the transition to value-based payment models. The ACCESS Model, which targets conditions like diabetes, hypertension, and chronic musculoskeletal pain, requires insurers to tie payments to specific health targets. If your lab results—such as HbA1c for diabetes or blood pressure readings—do not show a “reasonable expectation of improvement,” the insurance company may trigger a comprehensive review of your entire treatment plan. This means that staying on a stable medication for years no longer guarantees automatic coverage. You must now provide regular “Patient Reported Outcome Measures” (PROMs) to justify the continued expense.
1. GLP-1 and Obesity Management Reviews
With the JAMA-projected $250 billion fiscal impact of GLP-1 drugs, insurers are aggressively reviewing long-term users of medications like Wegovy and Ozempic. In 2026, many plans now require an “Effectiveness Review” every six months. If a patient hasn’t lost at least 5% of their body weight or shown improvement in metabolic markers, the insurer may reclassify the drug as “lifestyle” rather than “medical,” leading to a sudden loss of coverage. These reviews are specifically designed to weed out “maintenance” users who do not meet the new, stricter 2026 clinical guidelines.
2. Chronic Pain and Physical Therapy “Tapers”
Long-term patients receiving physical therapy or chiropractic care for chronic pain are facing new “Duration Limits” in 2026. Under the ACCESS Model’s musculoskeletal track, insurers are reviewing any therapy that extends beyond a 90-day window. These reviews often result in a “Mandatory Taper” plan, where the insurer forces a reduction in visit frequency unless the provider can prove that “Active Therapy” is superior to a home-based exercise program. For patients who have used these services for years to manage pain, this can feel like a sudden withdrawal of essential support.
3. Specialty Biologics for Autoimmune Conditions
For those with Rheumatoid Arthritis, Crohn’s, or Psoriasis, the 2026 “Step Therapy” reviews are becoming more frequent. Insurers are using newly approved biosimilars as a trigger to review long-term patients on expensive name-brand biologics. Even if you have been stable on a medication for five years, your insurer may conduct a “Marketplace Alignment Review,” requiring you to switch to a lower-cost biosimilar or face a massive increase in your co-insurance. These reviews often ignore “physician preference” in favor of the plan’s 2026 formulary cost-saving targets.
4. Continuous Glucose Monitor (CGM) “Re-Verification”
In 2026, Medicare Advantage plans have tightened the eligibility for long-term CGM use. To keep your device covered, you must now provide documentation every 12 months proving that you are still using insulin and that you are checking your blood sugar at least four times a day. Insurers are conducting “Utilization Audits” to identify patients who may have improved their condition to the point where they no longer “clinically require” a continuous monitor according to the 2026 “efficiency” definitions.
5. Home Health Care and “Independence” Reviews
Patients receiving long-term home health services are facing “Independence Re-Assessments” in 2026. Insurers are reviewing whether “personal care” services are being used as a substitute for “medical care.” Under new 2026 Skilled Nursing Facility (SNF) guidelines, if a patient’s condition is deemed “stable and chronic” rather than “acute and improving,” the insurance may attempt to shift the cost to the patient or a long-term care policy. These reviews often target seniors who have received home visits for more than six consecutive months.
6. Mental Health and “Progress Tracking”
Behavioral health patients on long-term therapy are seeing a rise in “Functional Assessment” reviews for 2026. Insurers are now using standardized depression and anxiety scales to determine if therapy is “producing measurable results.” If a patient’s scores remain stagnant for several quarters, the insurer may limit the number of covered sessions per month, arguing that the patient has reached a “functional plateau.” This “data-driven” approach often overlooks the long-term maintenance required for complex psychiatric conditions.
7. Dialysis and “Site-of-Service” Efficiency
For patients with Chronic Kidney Disease, the 2026 reviews are focused on the “Site of Service.” Insurers are conducting “Home-First Reviews” to see if long-term patients currently receiving in-center dialysis can be transitioned to lower-cost home dialysis models. If the review determines that home dialysis is clinically possible, the insurer may reduce the reimbursement for in-center care. This forces the patient to change their treatment location to save the plan money.
Preparing for Your 2026 “Clinical Audit”
The increase in coverage reviews represents a fundamental shift in how insurance companies view chronic care. In the new “Value-Based” era, being a stable patient is no longer enough; you must be a “progressing” patient to maintain full coverage. To protect your care, work with your doctor this month to ensure all your “Outcome Measures” and “Functional Goals” are clearly documented in your chart. If you receive a “Notice of Review,” don’t panic. It’s an opportunity to provide the updated clinical data that confirms your treatment is essential. Staying ahead of the data is the only way to stay ahead of the denial.
Has your long-term medication or therapy been “flagged” for a 2026 coverage review? Leave a comment below and let us know which condition or drug is being targeted.
You May Also Like…
- After January, These Common Health Items Are No Longer Covered by Insurance
- Insurance Claim Processing Delays Are Peaking in February
- Insurance Portals Are Showing Different Prices Than Paper Statements
- 7 Insurance Plan Letters Seniors Often Misread — With Costly Results
- 7 Medical Supplies Insurance Stops Covering After the Calendar Resets
Read the full article here
