Open Enrollment Intervals (OEPs) are sure occasions of yr when people can change their well being care protection. This useful resource supplies fundamental info on the annual OEPs in Medicare (Medicare.gov) and Coated California (CoveredCA.com) for the 2026 plan yr and highlights points which might be of explicit relevance to helping low-income older adults.
Medicare Open Enrollment
Medicare enrollees have the chance to alter their present well being and prescription drug protection in the course of the Medicare OEP starting October 15. It’s notably essential for enrollees in Medicare Benefit (MA) and Prescription Drug Plans to overview their protection choices every year as plans can change their cost-sharing, supplier networks, and drug formularies from yr to yr.
Who: People at present enrolled in Medicare Elements A or B (Conventional Medicare), Half C (Medicare Benefit), and Half D (prescription drug protection) ought to overview their protection to verify they select essentially the most inexpensive choices to fulfill their wants in 2026.
When: October 15 to December 7, 2025.
What: Medicare enrollees at present in Conventional Medicare can:
- Stay of their present protection;
- Change to a brand new Prescription Drug Plan; or
- Be part of a Medicare Benefit plan.
Medicare enrollees at present in Medicare Benefit can:
- Stay of their present protection;
- Change to a brand new Medicare Benefit plan; or
- Return on Conventional Medicare by enrolling in a standalone Prescription Drug Plan.
Any modifications to protection take impact January 1, 2026.
How: Encourage your purchasers to make an appointment with the Well being Insurance coverage Counseling & Advocacy Program (HICAP) (1-800-434-0222) totally free help. Protection modifications could be made at Medicare.gov or 1-800-MEDICARE.
Ideas for utilizing Medicare Plan Finder
The Facilities for Medicare and Medicaid (CMS) gives a web based device known as the “Medicare Plan Finder” for evaluating Medicare Benefit and Half D Prescription Drug Plan choices.
Medicare Plan Finder gives many particulars about plan choices, together with:
- The plan’s premiums, deductibles, cost-sharing, and out-of-pocket most;
- Whether or not a drugs is at present on the plan’s formulary, and whether or not it’s topic to prior authorization or different utilization administration restrictions;
- For supplemental advantages (e.g., imaginative and prescient, dental, in-home care), what limits and cost-sharing apply. Please word that some supplemental advantages are restricted to a subset of enrollees; these eligibility limits might not seem on Medicare Plan Finder.
Medicare Plan Finder permits customers to filter by sort of plan, together with Particular Wants Plans designed for people enrolled in each Medicare and Medicaid (often known as twin eligible particular wants plans, or D-SNPs). The California Medi Medi Plan D-SNPs are increasing to 29 new counties, at the moment are open for 2026 enrollment, and could be discovered on Medicare Plan Finder. The Medi Medi Plans are provided by the identical insurance coverage firms working Medi-Cal plans and supply enhanced coordination with Medi-Cal providers.
When utilizing Plan Finder, right here are some things to think about:
- Supplier networks: In case your shopper want to proceed seeing their suppliers subsequent yr, reviewing the Medicare Benefit plan community and asking whether or not their suppliers shall be in-network is essential. Relying on the plan, seeing an out-of-network supplier can lead to a denial of protection or greater price sharing to your shopper. This solely applies to Medicare Benefit plans. Supplier directories could be discovered on plan web sites, and (newly for this yr) may seem on Medicare Plan Finder. Directories could be fairly inaccurate; if there’s a supplier that your shopper desires to verify is roofed, it’s a good suggestion to contact that supplier and ask if they are going to be in community.
- Prescription drug wants: In case your shopper takes prescription drugs, the plan’s formulary or checklist of coated medicine, can even be essential to overview. If a number of prescription drugs will not be on the plan’s formulary, this can lead to a denial of protection topic to the Half D appeals course of. This is applicable to each Medicare Benefit plans and standalone Prescription Drug Plans.
- Pharmacy networks: In case your shopper has a neighborhood pharmacy that they want to proceed to go to, and to make sure that they save essentially the most cash, it is going to be essential to overview the plan’s most well-liked pharmacy community checklist. Going to a non-preferred pharmacy can lead to greater price sharing to your shopper. This is applicable for each Medicare Benefit plans and standalone Prescription Drug Plans.
- Supplemental advantages: Evaluation eligibility and protection limitations rigorously. In case your shopper is dually enrolled in Medi-Cal and Medicare, contemplate whether or not supplemental advantages provided overlap with Medi-Cal protection. This is applicable to Medicare Benefit plans.
The quantity of knowledge to think about could be daunting. HICAP counselors have been educated on plans within the native space in addition to modifications to the Plan Finder device. They’re conscious of points with how info is offered that could be complicated and are in one of the best place to make sure enrollees are making knowledgeable selections. As an extra useful resource when contemplating Medicare Benefit plan choice, see Justice in Growing old’s Twin Eligible Particular Wants Plans FAQ and the Medicare Rights Heart’s Inquiries to Ask earlier than Becoming a member of a Medicare Benefit Plan.
Ideas for Making Certain Your Shoppers Are Not Overpaying for Medicare Protection
When purchasers are reviewing their protection and enrollment choices, it’s also a possibility to guarantee that they’re enrolled in all applications for which they qualify. Regardless of being eligible, many individuals will not be enrolled within the Half D Low Revenue Subsidy (LIS or “Further Assist”) program, which reduces prescription drug prices, or the Medicare Financial savings Packages, such because the Certified Medicare Beneficiary (QMB) program, which pays for premiums and cost-sharing together with each Half B premiums and likewise Half A premiums for individuals with out free Half A. Serving to purchasers get enrolled in these applications can save them 1000’s of {dollars} per yr and allow them to entry care they could in any other case forgo as a consequence of price.
As is the case with different Medicare enrollees, plan selection can have an effect on the quantity that LIS enrollees pay in Half D premiums. 600 thousand Medicare enrollees with the LIS pay a Half D premium as a result of they don’t seem to be enrolled in a premium-free plan (also referred to as a “benchmark” plan). Open Enrollment is one of the best alternative for these people to overview their protection and alter plans if vital to raised meet their wants and get monetary savings.
Listed below are tips about assist your purchasers keep away from overpaying for his or her protection:
- Familiarize your self with the tan “Choosers” discover despatched to LIS enrollees so you possibly can assist your purchasers perceive their choices.
- Ask all of your low-income purchasers whether or not they’re paying a Half D premium. If they’re or don’t know, urge them to overview their choices with a HICAP counselor.
- Do not forget that LIS enrollees can change plans on a month-to-month foundation. If at any time in the course of the yr, you study that an LIS shopper is paying Half D premiums, urge the shopper to overview all plan choices and contemplate altering plans.
Ideas for Altering Medicare Protection Throughout Different Instances
Generally, people can change their Medicare Benefit or Half D Prescription Drug Plan outdoors of the annual Medicare OEP. For instance, if an individual has just lately misplaced Medi-Cal protection, moved, or skilled modifications within the plan choices accessible to them, they might be eligible for a Particular Enrollment Interval designed to assist people be part of plans, change plans, or disenroll from Medicare Benefit.
Individuals dually enrolled in Medicare and Medi-Cal, people enrolled in LIS, and people dwelling in nursing properties are a number of the people who’ve Particular Enrollment Intervals accessible to them. Medicare Benefit enrollees may change plans or change to Conventional Medicare between January 1st and March 31st of the yr in the course of the Medicare Benefit Open Enrollment Interval.
A brand new and momentary Particular Enrollment Interval shall be accessible in 2026 for enrollees who obtained incorrect Medicare Benefit supplier listing info from Medicare Plan Finder. For a full checklist of the completely different occasions and conditions that may benefit modifications to Medicare protection outdoors of a delegated enrollment interval, see CMS’ Particular Enrollment Intervals.
Coated California Open Enrollment
Older adults who will not be eligible for Medicare and do not need different medical health insurance can use the annual fall Market Open Enrollment Interval (OEP) to enroll in or change 2026 protection by means of Coated California. That is an choice for some older immigrants who’re ineligible for Medi-Cal and should pay a premium for Half A as a result of they don’t have ample work historical past.
(Notice that H.R. 1 takes away premium tax credit score eligibility for individuals with revenue beneath 100% FPL who’re ineligible for Medicaid due to their immigration standing).
It is very important rigorously overview plans, particularly this yr. Premiums are anticipated to almost double on common in California subsequent yr if Congress doesn’t act to increase enhanced premium tax credit expiring December 2025.
Who: Shoppers who will not be eligible for Medicare and do not need different medical health insurance protection can enroll in or change protection throughout open enrollment. Those that are eligible for Medicare however should pay a premium for Half A protection even have the choice to enroll in a Coated California plan however can pay penalties in the event that they later determine to modify to Medicare. See Medicare and the Market.
Notice: Shoppers ought to enroll in Medicare as quickly as they’re eligible to keep away from incurring late penalties. Enrolling in Coated California doesn’t postpone a person’s Medicare preliminary enrollment interval and will expose the person to late enrollment penalties in addition to legal responsibility for any tax credit obtained for Coated California protection. Shoppers not sure about selecting Coated California or Medicare with premium Half A ought to contact the HICAP to raised perceive prices and choices.
When: This yr, the Coated California Open Enrollment interval is November 1, 2025 to January 31, 2026. Shoppers who need their plan to begin on January 1, 2026 should join by December 31, 2025.
Notice: The open enrollment interval in California is longer than the Marketplaces operated by the federal authorities. Purposes for Medi-Cal and Coated California monetary help could be submitted year-round. Any modifications in revenue or family dimension for present enrollees must be reported as quickly as they happen.
What: Shoppers can enroll in or change well being and dental plans accessible by means of Coated California. Shoppers may select to be screened for premium tax credit score and cost-sharing discount eligibility in addition to Medi-Cal eligibility.
How: Shoppers can go to www.coveredca.com or name 1-800-300-1506 to use and to replace info. Native, free in-person help can be accessible by means of www.coveredca.com/find-help/.
Notice: HICAPs, 1-800-Medicare, and Coated California present free interpreter providers for people with restricted English proficiency (LEP). Advocates ought to encourage their purchasers to ask for language help in order that they will higher perceive their selections and get all their questions answered. Advocates also needs to remind purchasers that all year long, they will ask their plans totally free interpreter help when they don’t perceive a plan communication or in the event that they want different help.
Ideas for Altering Coated California Protection Throughout different Instances
Generally, people can change their Coated California protection outdoors of the Market OEP. For instance, if a person has just lately misplaced Medi-Cal, or skilled a life change like transferring, marriage, or dying of a family member, they could be eligible for a Particular Enrollment Interval. Study extra at Coated California: Particular Enrollment.
Upcoming Adjustments to Market Protection
Market enrollment, premium subsidy eligibility and verification, and particular enrollment intervals might all be topic to important modifications underneath the passage of finances reconciliation this summer time and the finalization of a Market rule. Many of those modifications are at present stayed by litigation, however this will likely change sooner or later. Encourage your purchasers to verify they’re receiving and reviewing notices about their plans, in case further actions are required by rule modifications.
Sources
- Medicare & You Handbook 2026 (accessible in Spanish, Chinese language, Korean, Vietnamese, and various codecs like massive print, audiobook, e-book, and Braille). Arabic, Russian, and Tagalog translations can be found for Medicare & You 2025.
- Medicare and the Market, Healthcare.gov
- Six Issues to Find out about Fall Open Enrollment, Medicare Rights Heart
- Medicare Open Enrollment Sources for Older Adults, Nationwide Council on Growing old
- Medicare Open Enrollment FAQs in English and Spanish, KFF
- Market Enrollment FAQs in English and Spanish, KFF
- Federal Adjustments to Your Well being Insurance coverage, Coated CA
- Justice in Growing old’s nationwide model of the Open Enrollment reality sheet for 2026
