Preparing for Open Enrollment - Employer and Healthcare Marketplace Plans

 Preparing for Open Enrollment - Employer and Healthcare Marketplace Plans

Key dates (Marketplace)

  • Nov 1, 2025 – Jan 15, 2026: Open Enrollment for 2026 coverage in HealthCare.gov states. Enroll by Dec 15 for Jan 1 start; Dec 16–Jan 15 enrollments usually start Feb 1. 

  • Some state marketplaces have their own sites/dates (e.g., Illinois moves to a state-based marketplace for 2026). Always check your state’s portal. 

Before you compare anything (both Employer & Marketplace)

  1. List your care & costs

  • Providers you want to keep (doctors/hospitals), preferred pharmacy, planned procedures/therapies in 2026.

  • Med list (name/dose/qty) + what you paid this year (premium + deductible + copays + coinsurance + Rx).

  • Any life changes coming (marriage, baby, moving, job change).

  1. Pull your documents

  • Employer: your 2026 benefits guide, plan SBCs, ANOC/EOC if provided, wellness/tobacco rules, life/disability options, HSA/FSA elections.

  • Marketplace: last year’s plan details + create/log in at HealthCare.gov (or your state site) and update your application/profile. 

If you have an Employer plan

What to review

  • Total cost of care: monthly premium plus deductible, copays/coinsurance, and out-of-pocket max.

  • Network: are your doctors/hospital and pharmacy in-network for 2026?

  • Rx formulary: tiers, prior auth/step therapy changes.

  • Spouse/dependent rules: spousal surcharge? proof of other coverage?

  • Wellness/tobacco surcharges and how to avoid them (attestations, programs).

  • Life/disability/EAP: consider supplemental life and STD/LTD; EOI may be required.

HSA/HDHP facts for 2026

  • HSA contribution limits: $4,400 self-only / $8,750 family (+$1,000 catch-up if 55+).

  • HDHP minimum deductibles: $1,700 self-only / $3,400 family.

  • HDHP out-of-pocket max (not counting premiums): $8,500 self-only / $17,000 family. 

Health FSA (employer)

  • Health FSA 2026 salary-reduction limit: $3,400.

  • Typical carryover cap (if plan allows): $680 for plan years beginning in 2026. (Your employer can allow less.) 

“Affordability” tip (why it matters for Marketplace eligibility)

  • An employer offer is “affordable” for 2026 if the employee-only premium for the lowest-cost plan ≥ does not exceed ~9.96% of household income; if it’s affordable and meets minimum value, you generally won’t qualify for Marketplace premium tax credits. 

Employer checklist (quick)

  • □ Compare at least two employer plan options using your doctors/Rx and your 2026 care expectations.

  • □ Decide: PPO vs HDHP (+HSA). If HDHP, set HSA payroll contributions.

  • □ Elect FSA (or Limited-Purpose FSA if you have HSA) and set an intentional number (don’t overfund).

  • □ Review life/disability/EAP; complete any evidence-of-insurability.

  • □ Submit any required wellness/tobacco attestations.

If you’re shopping the ACA/Marketplace

Dates & where to enroll

  • HealthCare.gov states: Nov 1–Jan 15 (Dec 15 for Jan 1 start; later selections usually start Feb 1). Your state may differ—check your state marketplace site. 

What to get ready

  • Income (MAGI) estimate for 2026, household size, immigration status if applicable, and documents if requested.

  • Your doctor/pharmacy list and med list to filter plans by network and Rx formulary.

  • Understand metal levels (Bronze/Silver/Gold/Platinum) and how cost-sharing works (deductible vs copay vs coinsurance).

Important 2026 context (subsidies & prices)

  • As of Nov 4, 2025, the ARPA/IRA enhanced premium tax credits are set to expire after 2025 unless extended. Multiple analyses show 2026 net premiums could rise for many if that happens. Build scenarios with and without enhanced subsidies when you compare. 

Marketplace checklist (quick)

  • □ Update your HealthCare.gov (or state) application; reconfirm income & household. 

  • □ Filter plans to in-network providers and covered meds first; then compare total yearly cost.

  • □ If income may qualify you for cost-sharing reductions (CSR), focus on Silver plans.

  • □ Verify effective date (Jan 1 vs Feb 1) based on when you enroll; pay first premium on time to activate. 

How to compare plans (works for both Employer & Marketplace)

  1. Start with “must-haves”: your doctors/hospital, your meds/formulary, and your chronic-care needs.

  2. Calculate annual cost for each plan you’re considering:

    • (12 × premium) + expected copays/coinsurance + deductible you’re likely to meet (use last year’s usage as a guide).

    • Consider worst-case: if something big happens, what’s the plan’s out-of-pocket max?

  3. Extras that matter: pre-deductible services, virtual care, behavioral health, Rx tiers for your meds, GLP-1/biologic rules, out-of-network coverage, travel coverage, dental/vision add-ons, and prior-auth policies.

  4. Tie-breakers: plan quality ratings, customer service, and how easy it is to get care. (Marketplace star ratings are shown during shopping.)

Pro tips (rapid-fire)

  • Don’t chase premium alone—a low premium with your doctors out-of-network or higher Rx tiers usually costs more.

  • If you have an employer HDHP, front-load HSA contributions if you expect early-year expenses (but mind cash flow). 

  • FSAs are use-it-or-lose-it (unless your plan has a carryover or grace period). Don’t over-elect. 

  • Switching plans? Confirm refills and authorizations (especially for specialty meds) so you don’t hit a January gap.

  • If you lose employer coverage or have a life event, you may qualify for a Special Enrollment Period instead of waiting.

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