The changes in Medicare and Individual & Family health insurance for 2026
As summer moves away and we slowly move towards fall. We’re getting prepared for 2026 health insurance enrollment. The federal climate makes the year interesting with some changes. No matter what’s changing, we want you to know that we care, and we are here to help you! Here are a few important updates. Please read and pass along this information; it’s relevant to everyone.
MEDICARE
Annual Election Period (AEP) begins Oct.15 to Dec. 7 for Medicare and Part D. Most of the changes are associated with Medicare Advantage plans.
- Some Medicare Advantage plans are being discontinued in several counties: If you receive a notice that your plan is no longer available in your county, and you do nothing, you could end up on Original Medicare. Please contact us to find out what plans will be offered in your area
- D-SNP, Benefit changes for Medicare - Medicaid recipients: The Value-Based Insurance Design (VBID) model will end Dec. 31, 2025. It means Medicare Advantage plans (D-SNP) for Medicare-Medicaid individuals could lose some benefits in non-health-related benefits. However, Medicare-Medicaid individuals who have a specific chronic illness will continue to receive non-health-related benefits
- C-SNP, The Special Supplemental Benefits for the Chronically Ill (SSBCI): allows Medicare Advantage plans with chronic illness (C-SNP) to offer additional non-health-related benefits like health foods, utility assistance, etc., to meet individual needs. You will see more C-SNP plans in 2026
- Part D- Prescription Drug Plan maximum out-of-pocket increase. In 2026, the maximum out-of-pocket is $2,100, a $100 increase from the year 2025
HELPFUL TIP
Don’t let your policy roll over!
Call us at 503-538-6022 to make sure your plan, your doctors, and medications are available for your 2026.
Individual & Family
Individual & Family: The Open Enrollment Period (OEP), Nov. 1st to Jan. 15. At this time, it's a waiting game to see if the enhanced premium tax credit to subsidize premiums will continue. If it expires, we expect to see a jump in higher premiums.
- Do Not Auto Renew: It’s very important to NOT let your policy roll over or “AUTO RENEW”. Why? There are changes in benefits and premiums!!
- Tax filing is needed: for Marketplace applicants who received a financial subsidy to lower the monthly premium and fail to reconcile the advanced premium tax credit (APTC), they will not be eligible for a tax credit in 2026. Please make sure your 2024 tax filing is completed. It means if you have not filed taxes or failed to reconcile subsidy dollars received (form 8962) in the previous year, you will be ineligible to receive financial subsidy and need to pay the full monthly premium
- APTC Repayment Cap ends in 2025: If your income has changed in 2025, we encourage you to update your income at healthcare.gov before OEP. In 2026, the Advanced Payment Tax Credit (APTC) Repayment cap has no cap or limitation. It means you will be required to pay back 100% of the subsidy when the IRS finds that your 2026 actual income is higher than the income on the marketplace application
- OHP Bridge: (basic OHP) recipients will lose coverage. For those who have income between 100%-138% they will need to enroll in the Marketplace for coverage
- Citizenship: Deferred Action for Childhood Arrival (DACA) recipients will no longer be eligible for financial assistance via the marketplace. Effective Aug. 25, 2025, their plans will be terminated. Non-citizens whose income is under 100% FPL and who do not meet the 5-year requirement in the country are no longer eligible to receive tax credits. They will need to obtain health insurance and pay the full premium
- Gender affirming care is no longer an essential health benefit at the federal level. However, there is no change at the state level
- Pay back premium for non-premium payment: If you have stopped paying premiums in 2025 and let the policy lapse without a record of cancellation, such as a phone call to the insurance company or marketplace. Be aware that when you reapply in 2026 and select the same insurance company, you will need to pay the 2025 past due premium amounts as well as the 2026 new premium
- 2026 Bronze plans offered through marketplace are eligible for Health Savings Accounts (HSA). Whew! At least we have some good news. It means you gain tax advantages to open an HSA at your bank. Your deposited money is a tax deduction with accrued tax-free interest. You use the money to pay for your qualified medical expenses, such as copays, dental, and vision expenses, among others
BOTTOM LINE
Do not let your coverage roll over (auto-renew) for 2026 coverage!
Reviewing plans, inputting your information, and selecting a plan are critically important during the AEP for Medicare or OEP for individual and Family health insurance. We care and we commit to help you. It’s time for you to take action. Call us for a free consultation at (503) 538-6022 or visit www.ChehalemInsurance.com