Open Enrollment Guide for Patients (2026)

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

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 will pay for covered services in a year. After reaching this, insurance pays 100%.

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.

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)? 

Higher premium / lower deductible

Lower premium / higher deductible

Part A: Hospital care

Part B: Outpatient services, including infusion treatments in a doctor’s office or clinic

Optional add-ons:

Original Medicare does not cover:

Combines Parts A and B in one plan (usually includes Part D)

Run by private insurance companies

Could include “extras” like vision, dental, or hearing that Original Medicare Parts A & B do not (while charging higher premiums)

Cannot be combined with Medigap

Required to have an out-of-pocket maximum

Through an employer or private broker: Dates vary depending on employer or plan.

Health Insurance Marketplace (Healthcare.gov):

General Open Enrollment: Oct 15 – Dec 7, 2025
During this period, you can:

Medicare Advantage / Part C Open Enrollment: Jan 1 – Mar 31, 2026
During this period, you can:

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?

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

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

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

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

Bronze: Lowest premium, highest out-of-pocket costs

Silver: Moderate premiums, moderate out-of-pocket costs (subsidy-eligible)

Gold: Higher premiums, lower out-of-pocket costs

Platinum: Highest premiums, lowest out-of-pocket costs

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

Medicare General Enrollment: Oct 15 – Dec 7, 2025

Medicare Advantage Open Enrollment: Jan 1 – Mar 31, 2026

Marketplace Open Enrollment: Nov 1, 2025 – Jan 15, 2026 (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)

Loss of health coverage

Offer of new health benefits

Change in household (marriage, divorce, birth, adoption, death)

Change in residence

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