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Helping You Feel Calm About Needles
It’s Open Enrollment season!
Open Enrollment is the time each year when you can review and adjust your health insurance coverage. If you receive infusion therapies, the insurance plan you choose can directly affect your ability to keep accessing your treatment without interruptions or surprise costs.
This guide is designed to help you:
- Understand the differences between Medicare and Marketplace/commercial plans
- Learn key insurance terms in plain language
- See how deductibles, co-pays, and co-insurance affect your costs
- Keep track of important enrollment dates and deadlines
- Make informed decisions when choosing your health insurance
Types of Health Insurance with Open Enrollment
Medicare (Government Insurance)
Medicare is a government-funded program that offers healthcare coverage for people who are age 65 or older, disabled, or have end-stage renal disease (ESRD) or ALS (also called Lou Gehrig’s disease). Infusion therapies are most often billed under Medicare Part B (more on the different components of Medicare below). You can obtain Medicare coverage during specific Open Enrollment periods.
Marketplace Plans
The Affordable Care Act (ACA) created a competitive market for individual insurance known as the federal Health Insurance Marketplace, or HealthCare.gov. You can get coverage during Open Enrollment through the ACA marketplace or through state-run marketplaces. You can also work with a broker or health insurance company directly or buy a plan from a private exchange.
Key Terms Patients Should Know
- Premium: The monthly cost of maintaining insurance coverage.
- Deductible: What you must pay each year before insurance begins to share costs for certain services based on the plan benefits.
- Co-insurance: A percentage of the allowed amount for a service that you pay after meeting the deductible (e.g., 20%). The “allowed amount” is the maximum amount an insurance company has agreed to pay for a covered health care service.
- Co-pay: A flat fee for certain visits or medications.
- Out-of-pocket maximum: The most you pay for covered healthcare services in a year. Once you reach this limit, your insurance generally pays 100% of covered, in-network costs for the rest of the year. Monthly premiums and services your plan doesn’t cover do not count toward this limit.
- Formulary: The list of medicines covered by the plan. This is critical for infusion and specialty drugs.
- Prior authorization: Approval required by the plan before a medicine or treatment is covered.
- In-network vs. out-of-network providers: Staying in-network usually results in lower costs.
- Treatment administration fee: Charges for administering infusion therapies in a clinic, office, or hospital.
- Patient assistance programs: Manufacturer-provided discounts or copay assistance — note that not all plans count these toward a deductible or out-of-pocket maximum.
You should always check:
- Is your infusion medicine on the formulary?
- Does the plan require prior authorization for your treatment?
- Are your infusion providers in-network?
- What are you responsible for paying for your treatment? Is it a percentage of the cost of service (coinsurance) or a flat fee (copay)?
How Health Insurance Coverage Works
Here’s a simplified example:
Plan: $2,000 deductible, 20% co-insurance, $6,000 out-of-pocket maximum
Medical expense: $22,000 infusion treatment
- Patient pays the $2,000 deductible
- Then pays 20% of remaining $20,000 = $4,000
- Total patient responsibility = $6,000 (reaching out-of-pocket max)
- Insurance pays the rest = $16,000
This example is useful to show how large infusion costs can quickly push a patient to their out-of-pocket maximum, after which the insurance company is responsible for the rest.
Balancing Premiums and Deductibles
You should determine whether it’s better for you to choose a high-premium plan or a low-premium plan. Key points to share:
- Higher premium / lower deductible
- More expensive monthly payment
- Could save money in the long run if you have frequent infusion needs, since insurance likely starts covering sooner
- Tend to have lower out-of-pocket maximums and patient cost share
- Lower premium / higher deductible
- Less expensive monthly payment
- Could cost more overall if you require ongoing or high-cost treatments
- Tend to have higher out-of-pocket maximums and could have higher patient cost share once the deductible is met (e.g., 20% coinsurance vs. a $50 copay)
Medicare: What Infusion Patients Need to Know
Typically, Medicare enrollees choose between two paths:
1. Original Medicare (Parts A & B)
- Part A: Hospital care
- Part B: Outpatient services, including infusion treatments in a doctor’s office or clinic
- Optional add-ons:
- Medigap: Supplemental insurance to cover co-pays, co-insurance, and Part A deductibles
- Part D: Helps cover medicines taken at home
- Original Medicare does not cover:
- Routine dental care
- Most hearing services
- Eye exams and eyeglasses
- Long-term care
- Care while traveling outside the U.S.
2. Medicare Advantage (Part C)
- Combines Parts A and B in one plan (usually includes Part D)
- Run by private insurance companies
- Could include extra benefits like vision, dental, or hearing coverage.
- Cannot be combined with Medigap
- Required to have an out-of-pocket maximum
Medicare: Important Differences for Infusion Patients
IMPORTANT NOTE: If you switch from Medicare Advantage back to Original Medicare and wants to add Medigap, you could have to go through medical underwriting in most states. This means the insurer can look at your health condition(s) and charge more or deny coverage.
The Infusion Access Foundation recommends enrolling in Original Medicare from the start because it generally offers more provider choices and fewer prior authorization requirements.
If you’re 65 or older, you generally have a one-time, six-month period to buy Medigap without being denied coverage because of your health. This period starts when you’re 65 or older and enrolled in Medicare Part B. If you’re under 65, your ability to buy Medigap depends on your state’s rules.
We also recommend contacting your state’s State Health Insurance Assistance Program (SHIP), which are federally-funded agencies that provide local, in-depth, and objective insurance counseling and assistance to Medicare-eligible individuals, their families, and caregivers.
IMPORTANT EXCEPTION: If your Medicare Advantage plan is ending or will no longer be available in your area, you may have the right to buy certain Medigap plans when you switch to Original Medicare. This means you cannot be denied coverage or charged more because of your health conditions.
You can generally apply starting 60 days before your Medicare Advantage coverage ends and up to 63 days afterward.
Not every plan change qualifies. You do not automatically receive these protections just because your plan’s costs or benefits are changing or because you want to switch plans.
Keep any notices from your insurance company and contact Medicare or your State Health Insurance Assistance Program (SHIP) to understand your options and deadlines.
Important Dates for Open Enrollment
Marketplace
- Through an employer or private broker: Dates vary depending on employer or plan.
- Health Insurance Marketplace (Healthcare.gov):
- Nov 1 – Jan 15, 2027 – Open Enrollment period to review, enroll, or change plans.
- Dec 15, 2026 – Last day to enroll or make changes for coverage starting January 1, 2027.
- January 15, 2027: Last day to enroll in or change plans for coverage to start February 1, 2027.Note: Some states run their own marketplaces with different dates. Visit HealthCare.gov state Marketplace directory and search “State-Based Marketplaces 2027 Open Enrollment” to find state’s deadlines.
- Medicare Open Enrollment: Oct 15 – Dec 7, 2026
- During this period, you can:
- Choose Original Medicare (Part A and Part B) and possibly add Medigap
- Choose or change a Medicare Advantage (Part C) plan
- Choose or change a Part D prescription drug plan
- Medicare Advantage / Part C Open Enrollment: Jan 1 – Mar 31, 2027
- During this period, you can:
- Switch to a different Part C plan
- Switch from Medicare Advantage to Original Medicare, and possibly add Medigap (with potential medical underwriting)
- Add a Part D plan
Considerations When Choosing an Open Enrollment Plan
1. Review health needs
Start by evaluating your personal and family health needs:
- How often do you visit doctors or specialists?
- Do you have ongoing medical conditions requiring frequent or high-cost care?
- What prescriptions are necessary, especially infusion or specialty medicines?
- How often are infusions scheduled, and where are they administered?
2. Gather necessary information before applying
Be prepared with:
- Personal details (name, date of birth, ZIP code, Social Security numbers for household members)
- Proof of income (W-2 forms, pay stubs, or tax returns) — needed for subsidy eligibility
- Current health insurance details (if you have coverage already)
- Preferred providers, specialists, and infusion centers, so you can confirm network participation
- A list of regular prescriptions and infusion medicines
3. Check providers
Provider networks can directly impact care and costs:
- Confirm primary care physician, specialists, and infusion center are in-network (as out-of-network visits could result in significantly higher costs or uncovered services)
- Remember that Medicare Advantage plans have narrower networks than Original Medicare, which could limit access to established infusion sites
4. Check medicines
Many infusion medicines are covered under your insurance plan’s medical benefits rather than its prescription drug list (formulary). When comparing plans, ask your insurer how your specific infusion medicine is covered.
- Verify that each infusion medication is covered under the plan
- Ask whether prior authorizations are required, as these can delay therapy
- Check approval timelines, as some Marketplace or Medicare Advantage plans require new approvals each year even if you have been stable on therapy
5. Compare costs (not just premiums)
Focus only on the monthly premium does not take into account other costs of care, including:
- Deductibles: How much you must pay out-of-pocket before coverage begins
- Co-pays and co-insurance: What you’ll pay at each visit or per infusion
- Out-of-pocket maximum: The maximum financial responsibility in a year
- Infusion-related fees: Such as drug administration charges or facility costs
- Sometimes, a higher premium / lower deductible plan could save money overall, since infusions can quickly push you to your deductible or out-of-pocket maximum.
6. Understand Marketplace “metal tiers”
If you are considering Marketplace plans, understand the four levels:
- Bronze: Lowest premium, highest out-of-pocket costs
- Silver: Moderate premiums, moderate out-of-pocket costs
- Gold: Higher premiums, lower out-of-pocket costs
- Platinum: Highest premiums, lowest out-of-pocket costs
- For infusion patients, higher-tier plans could be more cost-effective long-term, since they reduce per-treatment expenses.
If you qualify for financial help with your monthly premium, you can use it with any metal-level plan. However, if you qualify for extra savings on deductibles, copays, and coinsurance, you generally need to choose a Silver plan to receive those savings.
7. Look into assistance programs
Some drug manufacturers offer copay or patient assistance programs for infusion medicines.
- Verify whether the insurance plan will apply these payments toward the deductible or out-of-pocket maximum
- Note that not all states require insurers to count manufacturer assistance, so you could reach your maximum more slowly than expected
8. Check eligibility for subsidies
Depending on your income, you may qualify for financial assistance to lower your monthly insurance premiums and other healthcare costs when purchasing a Marketplace plan.
Extra financial assistance that was available from 2021 through 2025 expired at the end of 2025. This means that you may pay more for Marketplace coverage in 2027.
Visit HealthCare.gov to see what savings you may qualify for and compare your options.
9. Mark important deadlines
Missing deadlines could leave you without coverage for the year. Dates to remember:
- Medicare General Enrollment: Oct 15 – Dec 7, 2026
- Medicare Advantage Open Enrollment: Jan 1 – Mar 31, 2026
- Marketplace Open Enrollment: Nov 1, 2026 – Jan 15, 2027 (Dec 15 for Jan 1 coverage)
- State-specific marketplace dates (refer to CMS.gov to see if your state has an exchange of its own)
10. Understand Special Enrollment Periods (SEPs)
If you miss Open Enrollment, you could still qualify for coverage changes due to:
- Loss of health coverage
- Offer of new health benefits
- Change in household (marriage, divorce, birth, adoption, death)
- Change in residence
After Enrollment
Once you’ve chosen a plan:
- Keep copies of your enrollment forms and insurance card
- Confirm your infusions and providers are covered
- Set a reminder for next year’s Open Enrollment
- Re-check your plan every year, as needs and costs can change
Conclusion
Choosing a health insurance plan can feel overwhelming, especially when you rely on infusion treatments. But by checking whether your medicines are covered, making sure your providers are in-network, and comparing real costs, you can find a plan that protects both your health and your finances in 2027.
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