What’s New in 2026 for Open Enrollment? 

Oct. 8, 2025 

This year brings new rules for Medicare and Health Insurance Marketplace health plans. Premiums, out-of-pocket costs and requirements for re-enrolling are changing, so be sure to check your plan and update your coverage during open enrollment. 

Medicare 

Premiums 

The basic Medicare premiums are rising, but without a cap passed under the 2022 Inflation Reduction Act, it would have been much higher.  

• Medicare premiums are set to increase in 2026, with Part B (which covers doctor visits and medical equipment) rising 11.6% from $185 to $206.50, and Part D (optional prescription drug coverage) base premiums expected to go up 6% from $36.78 to $38.99. 

Medicare Advantage 

Medicare Advantage plans can change their extra services, including dental, gym benefits and transportation. Check to see whether your plan is dropping or altering benefits you use before re-enrolling. 

Formularies & Prior Authorization 

Each Medicare drug plan has a formulary (list of covered drugs) which is updated yearly. Even if your arthritis drug is included, new rules like prior authorization — requiring your insurance to approve it beforehand — or step therapy — a requirement by your insurance that you try other, less expensive drugs first — might be applied. Review your plan’s 2026 formulary to see what your drug costs will be. 

Medicare Prescription Payment Plan (MPPP) 

The Medicare Prescription Payment Plan spreads out prescription costs across the year instead of having to pay large amounts at once. 

• If you used the MPPP in 2025, you’ll be automatically re-enrolled — unless you switch drug plans. So, if you choose a new plan, you must re-enroll for the payment plan. 

Drug Price Negotiations  

This will be the first year that Medicare’s negotiated drug prices go into effect for certain high-priced drugs, which plans are required to cover. For arthritis, this includes Enbrel and Stelara. To see more on this topic, visit CMS’ website on price negotiations. 

Infusion/Injection Site-of-Care Costs 

Some plans charge more if you receive treatment in a hospital outpatient setting versus an infusion center. If your treatment comes via infusion or injection, check your plan’s site-of-care costs. Using a specialty center rather than a hospital may cost less. 

Biosimilars vs. Brand-Name Drugs 

Insurance plans may select biosimilars (lower-cost alternatives) instead of brand-name biologics and require patients to switch to the biosimilar or to provide extra justification for why they can’t switch. For patients new to these kinds of drugs, plans may require you to try a biosimilar rather than the brand-name drug first (if available), unless you show that it isn’t suitable for you. These drugs have a similar effectiveness and safety but talk to your health care team if you have questions. 

Drug Adherence Support  

Programs that help ensure you stay on complex drug regimens can lower costs and improve outcomes. Ask whether your plan offers Medication Therapy Management (MTM) or specialty counseling to help manage your arthritis regimen. These services are often free under Medicare plans. 

Tracking Annual Drug Costs 

Because multiple medications add up, even small cost increases matter. If you take more than one drug for your arthritis, track your total annual drug spending before comparing plans. The difference in drug tiers (how much each plan charges for a drug), deductibles and out-of-pocket caps can add up. 

Health Insurance Marketplace Changes 

• For Marketplace plans, open enrollment for 2026 is expected to run Nov. 1, 2025, through Jan. 15, 2026, in most states. However, proposed rules may shorten that window in future years to Nov. 1 to Dec. 15. 

• No more automatic re-enrollment: If you’re eligible for subsidies, you’ll need to actively re-enroll each year. 

• If you do not re-enroll, you’ll be charged a monthly premium of $5 or more. 

• More paperwork: Marketplace enrollees will need to update information regarding their income, immigration status and other details every year, or risk losing coverage. 

FAQs 

1. What is the new out-of-pocket cost cap for Medicare Part D? 
   • In 2025, a new cap was introduced. For 2026, it will be $2,100 per year maximum for prescription drugs covered by Part D. This applies to in-network pharmacies; out-of-network pharmacy coverage depends on your plan. Be sure to check before using an out-of-network pharmacy.   
2. How does the spread-out payment option work? 
   • If you were enrolled in the Medicare Prescription Payment Plan in 2025, you will be automatically re-enrolled into the program. If you switched drug plans from 2025, participants will not be eligible for automatic re-enrollment and must actively re-enroll. The plan allows you to spread drug payments over the year, especially if you sign up at the beginning of the year, instead of paying a large amount at one time for your medications. This can help you manage your budget better.   
3. Will vaccines be free? 
   • Under federal law, most private health plans and federal programs must cover vaccines recommended through shared clinical decision-making without charging patients, as part of the required preventive services.  
   • To see more on vaccine coverage, please see our vaccine FAQ.  
4. I’m an immigrant. What changes can I expect? 
   • DACA Recipients 
     • As of August 25, 2025, DACA recipients are no longer eligible for marketplace coverage.  
   • Lawfully Present Immigrants 
     • Starting in 2026, lawfully present immigrants with income below 100% of the federal poverty level who are ineligible for Medicaid due to their immigration status will also be ineligible for premium tax credits (PTCs), which help to cover health insurance premiums.  
     • Only U.S. citizens, legal permanent residents, Cuban and Haitian entrants, and migrants covered under the Compacts of Free Association (COFA) will be eligible for premium tax credits. 
5. How will the drug price negotiations affect me? 
   • Starting in 2026, Medicare will begin implementing negotiated prices for certain high-cost medications to help make them more affordable. So far, negotiations include Enbrel and Stelara for 2026 and Otezla in 2027.  
6. What are the updates to the catastrophic plan? 
   • Catastrophic health insurance is a type of plan designed to provide essential coverage during emergencies and for preventive care, with very low monthly premiums and high deductibles. It’s available to individuals under 30 or those who qualify due to financial hardship, offering a cost-effective way to protect against major medical expenses while covering most preventive services at no cost. These plans do not provide full coverage. 
   • As of September 2025, catastrophic plans are open to anyone not eligible for subsidies, regardless of age. 
   • This may lower premiums for catastrophic plans but could raise them for standard Marketplace plans. 
7. How are Marketplace plans changing? 
   • There are many changes coming to Marketplace plans in 2026 that will impact all enrollees. The five main changes are: 
     1. Higher out-of-pocket maximum: $10,600 (up from $10,150). 
     2. $5 minimum premium: If you previously paid $0, you’ll now pay at least $5/month. 
     3. Active re-enrollment required: You must re-enroll each year. 
     4. Stricter income checks: If your reported income doesn’t match IRS records, you’ll need to provide proof. 
     5. Increased premiums: The Base Beneficiary Premium is rising from $36.78 to $38.99 (a 6% increase).