The end of the year is fast-approaching–and we’re looking ahead to 2026. The new year is often a time of joy and hopefulness. For far too many patients, it is also a time of exorbitant healthcare costs.

One major reason is that in January, many health insurance plans renew. This includes many commercial plans—whether employer- or Affordable Care Act (ACA)-sponsored. It also includes plans offered by government programs such as Medicare and TRICARE. 

When a patient enrolls in a new health plan or their plan renews at the start of the year, their out-of-pocket (OOP) maximum and deductible restart at zero. This means they pay a higher portion of their healthcare expenses than they would later in the year. And with the enhanced ACA Premium Tax Credit set to expire, significant increases in premiums, deductibles, and OOP costs could prove catastrophic for some patients in early 2026.

As navigators prepare for this season, they often face a sharp rise in their workloads. Many are busy helping existing patients evaluate and enroll in plans during Medicare and ACA Open Enrollment. They’re also reviewing and re-enrolling patients in calendar-based financial assistance programs, so support is in place by January 1.

With greater needs and demands on their time, it can be challenging for navigators and other staff to determine which cost-saving opportunities to prioritize—and for whom. 

Here are the top priorities when assisting commercially insured, government-insured, and uninsured patients:

Who: Patients with Commercial Insurance

Top Priorities:

1. Insurance Optimization

  • The first step in working with patients, no matter what type of insurance they have, is to evaluate their existing coverage and OOP maximum. For those enrolling in or renewing a plan via the ACA Marketplace, the deadline for coverage beginning January 1 is December 15. However, even if patients miss this deadline, those who signed up by January 15 and paid their premium will receive coverage beginning February 1. And if they’ve had a qualifying life event—such as a loss of health coverage, a change in household income, or a move—they may be eligible for special enrollment outside of these dates. Enrollment dates may also vary by state.
  • Right now, there’s a lot of uncertainty because ACA Premium Tax Credit enhancements, which have kept premiums low for qualifying patients since 2021, are set to expire at the end of the year. Navigators should monitor this scheduled policy change–and prepare to help patients who may see a steep increase in their premiums.

2. Manufacturer Copay Assistance

  • Whether the patient has employer-sponsored insurance or an ACA plan, they may be eligible for manufacturer copay assistance. These programs help offset costs associated with copays, as well as deductibles and coinsurance. For patients with high-cost chronic conditions, these resources can make a tremendous difference.
  • Navigators should look at the patient’s treatment plan and then determine whether copay assistance is available for their medications. Program availability, eligibility requirements, and enrollment processes vary based on the pharmaceutical company’s guidelines. The good news is that these resources are available throughout the year.

Who: Patients with Government Insurance

Top Priorities: 

1. Insurance Optimization

  • Navigators should ensure that patients with government insurance are enrolled in the most cost-effective plans. For patients 65 and older, Medicare open enrollment ended on December 7. However, as with commercially insured patients, Medicare beneficiaries may be eligible for special enrollment. If patients qualify, it’s valuable to review their current coverage and compare options.
  • Navigators should also make patients aware of programs such as Medicare Advantage, supplemental plans (Medigap), and the Medicare Savings Program, also known as Extra Help. Notably, Extra Help offers special enrollment once per quarter for the first three quarters of the year. Extra Help increased its income eligibility to 150% of the federal poverty level (FPL). In the past, some patients only qualified for partial Extra Help, but now, all qualifying patients receive full program benefits.
  • The Inflation Reduction Act set a limit on out-of-pocket prescription drug costs for those with Medicare Part D; this limit increases to $2,100 in 2026. Patients are also eligible to enroll in the Medicare Prescription Payment Plan (M3P), which allows them to pay their out-of-pocket costs in capped monthly payments (instead of all at once) at the pharmacy.
  • The end of the year is also a good time to check in with Medicaid patients to ensure they’re complying with any income documentation requests from state agencies. Recent policy shifts have added new eligibility conditions (including work requirements) for patients who want to maintain or enroll in Medicaid. Navigators should be ready to assist patients who may need to transition to an ACA plan.
  • Military personnel, veterans, and their families may qualify for TRICARE benefits. TRICARE open enrollment ends on December 9, but like Medicare, the program offers special enrollment.

2. Foundation Copay Assistance

  • Numerous charitable organizations such as the HealthWell Foundation, PAN Foundation, and the Patient Advocate Foundation offer copay assistance. However, unlike drug manufacturers, these organizations also offer funds to patients with government-sponsored insurance. Thus, navigators should explore available grants for patients who have Medicare, TRICARE, or Medicaid. Grants are typically disease-specific, based on the patient’s condition.
  • Many of these funds reopen in January. Now is the time to explore these options for qualifying patients. Many funds have a look-back period, so once the patient is enrolled, some claims may be covered retroactively.
  • Due to Medicare reform, some foundations have reduced the limits of their awards. Navigators should closely monitor these changes and consider enrolling patients in additional grants as needed.
  • TIP: If the grant amount isn’t enough to cover a patient’s costs–or a grant is pending but treatment needs to start right away–it’s worth exploring M3P for qualifying patients.

Who: Uninsured Patients

Top Priorities:

1. Insurance Enrollment

  • Start by asking an uninsured patient why they don’t have coverage. For example, a patient may respond that they lost their job and their employer-sponsored insurance. This gives navigators the opportunity to discuss Consolidated Omnibus Budget Reconciliation Act (COBRA) benefits—or special enrollment in an ACA plan.
  • Low-income patients may qualify for Medicaid based on their household income, age, disability, and other factors. Eligibility criteria varies by state; an online screening tool is available via Healthcare.gov. Medicaid enrollment continues year-round.
  • As noted above, some patients may have lost their coverage as a result of changing criteria. If this is the case, it’s important to check whether they lost coverage in error and if they can appeal and re-enroll.
  • Whether the best option is Medicaid, COBRA, an ACA plan, or another type of insurance, it’s crucial to educate patients and help them enroll in affordable coverage.

2. Free Drug Programs and Charity Care

  • Drug manufacturers may provide free or low-cost medications to patients without insurance. Free drug orders are typically handled by a provider’s specialty or infusion pharmacy team; navigators should coordinate with pharmacy colleagues to review treatment plans and enroll eligible patients.
  • Due to the dynamic nature of drugmakers’ assistance programs, some patients who were previously eligible for free drug programs may no longer qualify. Some manufacturers are also requiring eligible patients to enroll in the M3P Program or Extra Help before they consider their applications.
  • For these reasons, it’s even more urgent for navigators to help the patient enroll in an affordable insurance plan, so that they might be eligible for foundation assistance. Foundations typically have higher income eligibility but they only assist insured patients.
  • Hospitals and health systems may also have their own internal charitable funds. Federal law requires that nonprofit hospitals provide some level of charity care—and many for-profit hospitals also offer these resources. While policies vary by organization, these funds are generally intended for low-income and uninsured patients.

Leaning into Technology

Understanding financial assistance priorities is essential. However, even with this knowledge, the process of matching and enrolling patients is typically manual and time-consuming. 

Fortunately, technology solutions can automate the process and ensure patients secure the resources they need. TailorMed’s platform supports the work of financial navigators and other staff by:

  • Identifying patients in need: Drawing on data from EMRs and pharmacy systems, the platform flags financially at-risk patients—so that navigators can proactively help them before they face an unaffordable medical bill.
  • Maximizing benefits: The technology analyzes patients’ health coverage and provides options to optimize insurance, enroll in additional coverage, or switch plans. TailorMed’s partnership with Paytient also streamlines M3P enrollment, making it easier for Medicare beneficiaries to spread eligible prescription costs over time.
  • Finding comprehensive funding opportunities: With thousands of financial assistance programs in existence, it’s difficult to find every available resource for every patient. Drawing from 7,000-plus copay assistance programs, grants, and other resources, TailorMed automatically finds the most relevant opportunities and the swiftest way to enroll the patient.
  • Expediting enrollment: Through direct integrations with drug manufacturers’ assistance programs, TailorMed Express Enroll enables navigators to enroll patients without leaving our platform. This has led to time savings of up to 60%.
  • Addressing social determinants of health (SDOH): TailorMed can also help navigators identify funds to help offset nonmedical costs such as housing, transportation, food, and more. With patients feeling the pain of inflation, these resources can provide much-needed relief and peace of mind.
  • Notifying staff at the right time: The platform’s alerts let navigators know when relevant charitable funds reopen, so they don’t miss narrow application windows. Users can also see pending renewals, so they can re-enroll patients in relevant programs before they expire.
  • Centralizing navigation: Rather than relying on spreadsheets and Post-Its, navigators can manage their tasks, notes, patient approvals, internal communications, and other elements of their workflow in one location. The result is a more efficient experience, benefiting all parties involved.
  • Reaching more patients: With multiple responsibilities and limited time, navigators often aren’t able to help every patient in need. By automating workflows and enhancing productivity, technology empowers navigators to do more with the time and resources they have.

Removing Barriers to Care During Busy Season—and All Year

The end of the year can mean daunting workloads for financial navigators and other staff. By prioritizing insurance optimization and enrollment, then matching the right patients with the right resources with the help of technology, navigators can make the most of the season. Let’s start 2026 on the right foot—by helping patients afford care today and throughout the year.

To learn more about how TailorMed can help your organization expand access to essential treatment, reach out to our team.