The fall is a busy time for people who need to sign up for healthcare coverage through Medicare or the Affordable Care Act (ACA). Medicare Open Enrollment occurs from October 15 through December 7. Meanwhile, open enrollment for ACA Marketplace plans begins on November 1. The last day to enroll or change plans for ACA coverage to start on January 1 occurs on December 15, and open enrollment ends on January 15 in most states.

This year, open enrollment will bring new rules, cost-sharing changes, and enrollment process updates. Here’s what navigators and care teams should know to help patients avoid coverage gaps and reduce costs:

ACA Marketplace Updates

  • Medicaid eligibility changes increase Marketplace demand
    As states continue to reassess Medicaid eligibility–and recent policy shifts introduce new requirements and coverage rules–10 million people are expected to lose Medicaid coverage over the next decade. As a result, more patients will need ACA plans, especially near open enrollment. Navigators should be ready to support these transitions.
  • Changes to premium subsidies
    The enhanced premium tax credits that lowered Marketplace premiums since 2021 are scheduled to expire after 2025. Patients may see higher monthly premiums in 2026 if this support is not continued.
  • Stricter income verification
    Marketplaces will require more documentation, such as tax returns or pay stubs, to confirm income eligibility for premium savings. Early prep can prevent application delays. We may also see changes to the limits on how much households must repay if they receive more premium tax credits than they qualify for. Accurate income estimates and midyear updates are essential.
  • Fewer automatic re-enrollments
    In 2026, many patients who receive premium subsidies will need to actively confirm their plan. Otherwise, they could be moved into a plan that costs more or covers less.
  • Higher out-of-pocket maximums
    The 2026 maximum out-of-pocket limit for plans will increase to $10,600 for individuals. Patients with serious or chronic conditions may face higher costs.
  • Shorter enrollment window on the horizon
    Starting next fall, the open enrollment period is expected to run November 1 – December 15, with fewer deadline extensions. Navigators should start outreach early.

Medicare Updates

  • Cost protections continue
    The 2022 Inflation Reduction Act (IRA) expanded eligibility for full benefits under the Medicare Part D Low-Income Subsidy (LIS) Program (Extra Help), which assists qualifying enrollees with Part D premiums, deductibles, and cost-sharing. The IRA also imposed a $35 cap on monthly out-of-pocket costs for insulin. Both of these provisions will remain for 2026.
  • Part D out-of-pocket cap increases slightly
    The Part D annual out-of-pocket maximum will rise to $2,100 in 2026 (up from $2,000 in 2025). Patients with high medication costs may hit the cap quickly and then pay nothing for the rest of the year. Navigators should help patients plan for early-year expenses.
  • Drug price negotiations begin
    For the first time, Medicare will negotiate prices for 10 high-cost prescription drugs in 2026. This may lower out-of-pocket costs for beneficiaries who rely on these medications.
  • Prescription Payment Plan auto-renews
    The new Medicare Prescription Payment Plan (M3P) allows patients to spread drug costs over the year instead of paying large amounts upfront. Starting in 2026, enrollment will automatically renew.

Tips for Insurance Optimization

Choosing the right plan—or switching to a different plan—can be overwhelming for patients. Here are some tips to ensure they enroll in the most cost-effective plans:

1. Talk to patients about their existing coverage

Start by talking to your patients about their existing coverage.  As you help them review their current plan to find out what’s covered, use this checklist of questions:

  • Are your doctors in network for your current plan?
  • Is your preferred pharmacy in network?
  • Is your preferred health system in network?
  • Does your plan’s formulary include all the prescription medications that you need to take?

2. Check in with patients turning 65

Make a special point to check in with patients who are turning 65 and becoming eligible for Medicare. They may not fully understand how Medicare enrollment works. You can explain the differences between the Initial Enrollment Period, which begins when they turn 65 and lasts seven months, and the General Enrollment Period. How to find them: technology can help flag patients who are turning 65 and can now sign up for Medicare.

3. Consider other plan options

If your patient isn’t satisfied with their current plan, or they realize that their doctors, hospitals, or medications aren’t covered by their existing plan, you can encourage them to consider switching to a different plan during open enrollment.

Before they switch, you can encourage patients to assess their options and review the ratings for various plans. For example, they can visit  Healthcare.gov to review ACA plans and prices, or they can review Medicare plans and prices on the Medicare.gov website.

This year, Medicare’s Plan Finder will offer clearer cost estimates and benefit comparisons. This will make it easier to find the most affordable and comprehensive plan.

4. Educate patients on plan types

Patients may not understand the differences between plan types. For example, there are four types of plans that are certified by the ACA Health Insurance Marketplace: HMOs, PPOs, POSs, and EPOs. You can explain the major distinguishing factors about each plan and help them determine what might be most appropriate for them. They might be interested in switching from one type of plan to another, and the only time to do that is during open enrollment.

Meanwhile, Medicare beneficiaries can choose to stay in traditional Medicare or go with a Medicare Advantage plan. While some experts suggest Medicare Advantage can be more affordable, a patient must balance that benefit with downsides, such as geographical restrictions and closed provider networks. Patients can also switch Medicare Advantage plans.

This year, beneficiaries who were previously misled when choosing a Medicare Advantage plan may also qualify for a special enrollment opportunity to switch plans outside standard windows. Ask patients if they were confused or misinformed during 2025 enrollment and assist with transitions as needed.

5. Tutor patients on enrolling

You may not be able to enroll a patient in a health plan, but you can educate them and help walk them through the process.

6. Consider pre-enrollment education for yourself

There’s a lot to know, so if you or anyone else on your team needs to brush up on key points, it may be worth checking out educational opportunities. For example, CMS offers Navigator and Certified Application Counselor Training Courses.

The Future of Affordable Care

By following the tips above and staying abreast of relevant policy changes, navigators and other professionals can play a key role in ensuring patients understand their coverage and choose the best possible plans. 

But even with the right insurance, many patients will still face high out-of-pocket costs and logistical barriers. That’s where technology can help. Platforms like TailorMed can flag at-risk patients, streamline enrollment in support programs, and reduce administrative burden—allowing care teams to focus on what matters most: guiding patients through their care. With the right coverage and support, more patients can access the treatment they need–and achieve better outcomes.

To learn more about how TailorMed’s solutions can help your team expand access to treatment during open enrollment and beyond, get in touch with us.