As the 2026 Medicare fee schedule takes effect, its impact on workers’ compensation varies—some services see modest hikes, others remain largely unchanged. For agents, the key takeaway is that any renewal file containing high‑risk pharmacy claims must be re‑examined to ensure the premium estimate reflects the new fee schedule.
As a national WC PM, I’m watching how agents incorporate the new fee schedule into their renewal models, especially for specialty drug claims.
Why Medicare 2026 Fee Schedule Matters for Workers’ Comp
Risk & Insurance notes that the 2026 Medicare fee schedule changes are modest yet uneven across services, putting pressure on workers’ comp costs for claims heavily dependent on pharmacy benefits. Risk & Insurance
MedRisk’s CEO Sri Sridharan stresses that the shifting fee schedule is a key element in predicting future costs and managing exposure for high‑risk pharmacy claims. Risk & Insurance
What Agents Need to Do
- Identify high‑risk pharmacy claims: Flag any renewal file that includes pharmacy claims above a set dollar threshold (e.g., $5,000) or that involves specialty drugs.
- Pull the latest Medicare fee schedule: Download the 2026 fee schedule from the CMS website and compare the rates for the specific drug classes used in the client’s claims history.
- Recalculate cost impact: Adjust the projected claim cost for each flagged pharmacy claim by applying the new Medicare rates. Use the same methodology you used for the original estimate to keep the comparison consistent.
- Document the adjustment: In the renewal file, add a note that the premium estimate has been updated to reflect Medicare 2026 fee schedule changes. Include a brief explanation of the impact on the overall premium.
- Communicate with the underwriter: If the adjustment changes the exposure classification or the projected loss cost, discuss the implications with the underwriter and request any necessary re‑pricing or re‑classification.
- Update the renewal proposal: Reflect the new premium estimate in the proposal and ensure the client understands the reason for the change.
What This Means for Your Placements
By proactively reviewing Medicare fee schedule changes for high‑risk pharmacy claims, you’ll avoid surprises at renewal and demonstrate a data‑driven approach to pricing. Clients will appreciate the transparency, and you’ll position yourself as a proactive risk manager who keeps pace with regulatory shifts that directly affect their bottom line.
Sources
- Risk & Insurance (2026-08-19)
- Risk & Insurance (2026-08-18)
Tags: Medicare, pharmacy claims, workers comp, renewals