NICA 2027 Open Enrollment Guide for Providers

It’s Open Enrollment season!
Open Enrollment is the annual period when patients review and adjust their health insurance coverage. For patients receiving infusion therapies, insurance choices can significantly impact their ability to continue accessing treatment.

As a provider, you play an important role in informing patients about their options, which will help them avoid gaps in coverage, delays in treatment, or unexpected costs. 

This guide is designed to help you:

• Understand key differences between Medicare and Marketplace/commercial plans
• Explain insurance terms clearly in conversations with patients
• Illustrate how deductibles, co-pays, and co-insurance affect overall costs
• Provide important enrollment dates and reminders

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Types of Health Insurance with Open Enrollment

Medicare (Government Insurance)

Medicare is a government-funded program that offers healthcare coverage for people who are age 65 or older, disabled, or have end-stage renal disease (ESRD) or ALS (also called Lou Gehrig’s disease). Infusion therapies are most often billed under Medicare Part B (more on the different components of Medicare below).

Marketplace Plans

The Affordable Care Act (ACA) created a competitive market for individual insurance known as the federal Health Insurance Marketplace, or HealthCare.gov. Individuals and families can enroll through HealthCare.gov or a state-run Marketplace. Patients can also get enrollment assistance from a certified assister, agent, broker, or enrollment partner.

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Marketplace Costs Changed After Enhanced Subsidies Ended

The temporary enhanced ACA premium tax credits expired at the end of 2025, reducing financial assistance for many Marketplace enrollees. Standard premium tax credits are still available in 2027 for eligible households, generally with incomes between 100% and 400% of the federal poverty level.

Marketplace enrollment fell from about 21.8 million people in 2025 to 19.2 million in 2026, according to KFF. The decline coincided with the expiration of enhanced subsidies and higher consumer premiums, although other factors also contributed.

For patients who rely on regular infusions or other high-cost care, it is especially important to compare total yearly costs, not just monthly premiums. Patients should review deductibles, co-insurance, out-of-pocket maximums, provider networks, and coverage requirements before selecting a plan.

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Key Terms Patients Should Know

• Premium: The monthly cost of maintaining insurance coverage.
• Deductible: What the patient 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 the patient pays 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 a patient will pay for covered, in-network services in a plan year. After reaching it, the plan generally pays 100% of covered in-network costs.
• 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.

Infusion patients should always check:

• Is your infusion medicine covered by the plan?
• 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)? 

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How Health Insurance Coverage Works

Here’s a simplified example:

Plan: $2,000 deductible, 20% co-insurance, $6,000 out-of-pocket maximum
Medical expense: $22,000 infusion treatment

1. Patient pays the $2,000 deductible
2. Then pays 20% of remaining $20,000 = $4,000
3. Total patient responsibility = $6,000 (reaching out-of-pocket max)
4. Insurance pays the rest = $16,000

This example is useful to show patients how large infusion costs can quickly push them to their out-of-pocket maximum.

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Balancing Premiums and Deductibles

Patients could ask whether it’s better to choose a high-premium plan or a low-premium plan. Key points to share:

• Higher premium / lower deductible
  • More expensive monthly payment 
  • Could  save money for patients with frequent infusion needs in the long run, since insurance likely starts covering sooner
  • Tend to have lower out-of-pocket maximums and patient cost share
• Lower premium / higher deductible
  • Less expensive monthly payment
  • Could cost more overall if the patient requires ongoing or high-cost treatments
  • Tend to have higher out-of-pocket maximums and could have higher patient cost share once the deductible is met (e.g., 20% coinsurance vs. a $50 copay)

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Medicare: What Infusion Patients Need to Know

Typically, infusion patients choose between two paths:

1. Original Medicare (Parts A & B)

• Part A: Hospital care
• Part B: Outpatient services, including infusion treatments in a doctor’s office or clinic
• Optional add-ons:
  • Medigap: Supplemental insurance that can help pay some of the out-of-pocket costs not covered by Original Medicare.
  • Part D: Helps cover medicines taken at home
• Original Medicare does not cover:
  • Routine dental care
  • Most hearing services
  • Eye exams and eyeglasses
  • Long-term care
  • Care while traveling outside the U.S.

2. Medicare Advantage (Part C)

• Combines Parts A and B in one plan (usually includes Part D)
• Run by private insurance companies
• Could include “extra” benefits like vision, dental, or hearing. Premiums and cost sharing vary by plan.
• Cannot be combined with Medigap
• Required to have an out-of-pocket maximum

Medicare: Important Differences for Infusion Patients

Question	Original Medicare (Parts A & B)	Medicare Advantage (Part C)
Can I see my doctor?	Any provider who accepts Medicare.	Usually subject to a plan network; some plans allow out-of-network care at a higher cost.
Are infusions covered?	Yes, under Part B; usually no pre-approvals	Often require pre-approvals, which could delay treatment
Out-of-pocket costs?	Premiums: Part A: $0 for most Part B: Standard Part B premium ($202.90 in 2026, 2027 projected $209.50)Deductibles: Medicare sets Part A and Part B deductible amounts annually; the Part A hospital deductible applies per benefit period.Annual cost limit: No limit, unless a patient has Medigap (which could bring Part B costs down to $0)	Premiums: Vary by plan. Part C premium is in addition to any required premiums for Part A and Part BDeductibles: Vary by plan Annual cost limit: Limit varies by plan. Medigap is NOT available under Medicare Advantage coverage
Flexibility?	Can add Medigap and Part D	Locked into network and plan rules. Most Medicare Advantage plans include Part D prescription drug coverage. Rules for adding separate Part D coverage depend on the type of Medicare Advantage plan.

Patients can compare Original Medicare and Medicare Advantage directly through Medicare.gov.

IMPORTANT NOTE: If a patient switches from Medicare Advantage back to Original Medicare and wants to add Medigap, they could have to go through medical underwriting in most states. This means the insurer can look at their health condition(s) and charge more or deny coverage.

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Important Dates for Open Enrollment

Marketplace

• Health Insurance Marketplace (Healthcare.gov):
  • Nov 1, 2026 – Jan 15, 2027 – Open Enrollment period to review, enroll, or change plans.
  • Dec 15, 2026 – Last day to enroll or make changes for coverage starting January 1, 2027.
  • Jan 15, 2027 – Last day to enroll or make changes for coverage beginning Feb 1, 2027. 
  • Note: Some states run their own Marketplaces with different enrollment dates. Visit HealthCare.gov to find your state’s Marketplace and confirm applicable deadlines.

Medicare

• Medicare Open Enrollment:Oct 15 – Dec 7, 2026
  During this period, patients can:
  • Choose Original Medicare (Part A and Part B) and possibly add Medigap
  • Choose or change a Medicare Advantage (Part C) plan
  • Choose or change a Part D prescription drug plan
    
• Medicare Advantage / Part C Open Enrollment:Jan 1 – Mar 31, 2027
  During this period, patients can:
  • Switch to a different Part C plan
  • Switch from Medicare Advantage to Original Medicare, and possibly add Medigap (with potential medical underwriting)
  • Add a Part D plan

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Considerations to Communicate to Patients in Choosing an Open Enrollment Plan

1. Review health needs

Encourage patients to start by evaluating their personal and family health needs:

• How often do they visit doctors or specialists?
• Do they 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?

2. Gather necessary information before applying

Patients should be prepared with:

• 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 they have coverage already)
• Preferred providers, specialists, and infusion centers, so they can confirm network participation
• A list of their regular prescriptions and infusion medicines

3. Check providers

Stress to patients that provider networks can directly impact their care and costs:

• Confirm their primary care physician, specialists, and infusion center are in-network
• Explain that out-of-network visits could result in significantly higher costs or uncovered services
• Remind patients that Medicare Advantage plans have narrower networks than Original Medicare, which could limit access to their established infusion site

4. Check medicines

Infusion patients need to ensure their treatments are covered by their plan. They should:

• 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 the patient has been stable on therapy

5. Compare costs (not just premiums)

Patients often focus only on the monthly premium, but total cost of care includes:

• Deductibles: How much they must pay out-of-pocket before coverage begins
• Co-pays and co-insurance: What they’ll pay at each visit or per infusion
• Out-of-pocket maximum: The most a patient will pay for covered, in-network services in a plan year. After reaching it, the plan generally pays 100% of covered in-network costs.
• Infusion-related fees: Such as drug administration charges or facility costs

Sometimes, a higher premium / lower deductible plan could save money overall, since infusions can quickly push them to their deductible or out-of-pocket maximum.

6. Understand Marketplace “metal tiers”

If patients are considering Marketplace plans, explain the four levels:

• Bronze: Lowest premium, highest out-of-pocket costs
• Silver: Moderate premiums, moderate out-of-pocket costs (cost sharing reduction eligible)
• Gold: Higher premiums, lower out-of-pocket costs
• Platinum: Highest premiums, lowest out-of-pocket costs

For infusion patients, higher-tier plans could be more cost-effective long-term, since they reduce per-treatment expenses.

7. Look into assistance programs

Some drug manufacturers offer copay or patient assistance programs for infusion medicines. Patients should:

• 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 patients could reach their maximum more slowly than expected

8. Check eligibility for Marketplace financial assistance

Patients purchasing coverage through the Marketplace may still qualify for financial assistance in 2027.

Premium tax credits can lower a patient’s monthly insurance premium. Eligibility is based on household income and other factors. Following the expiration of the enhanced ACA premium tax credits at the end of 2025, federal premium tax credits are generally available to eligible households with incomes between 100% and 400% of the federal poverty level.

Some patients may also qualify for cost-sharing reductions, which lower deductibles, co-payments, co-insurance, and out-of-pocket maximums. Patients must enroll in an eligible Silver plan to receive these additional cost-sharing savings.

Because eligibility and the amount of assistance depend on household income and circumstances, encourage patients to complete a Marketplace application rather than assuming they will or will not qualify for financial help. Patients can also find a Marketplace-certified assister or broker through HealthCare.gov’s Find Local Help tool.

9. Mark important deadlines

Missing deadlines could leave patients without coverage for the year. Remind them of:

• Medicare General Enrollment: Oct 15 – Dec 7, 2026
• Medicare Advantage Open Enrollment: Jan 1 – Mar 31, 2027
• Marketplace Open Enrollment: Nov 1, 2026 – Jan 15, 2027 (Dec 15, 2026 for Jan 1, 2027 coverage)
• State-specific marketplace dates (refer them to Healthcare.gov if needed)

10. Understand Special Enrollment Periods (SEPs)

If patients miss Open Enrollment, they could still qualify for coverage changes due to:

• Loss of health coverage
• Offer of new health benefits
• Change in household (marriage, divorce, birth, adoption, death)
• Change in residence

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After Enrollment

Once a patient has chosen their plan, remind them to:

• Keep copies of enrollment forms and insurance cards
• Confirm that infusion treatments and providers are covered
• Set a reminder for next year’s Open Enrollment
• Revisit plan every year, as needs or finances can change

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Conclusion

Choosing health insurance can feel overwhelming for patients, especially those who rely on infusion treatments. But by checking coverage for medicines, confirming providers, and comparing real costs, patients can choose a plan that protects both their health and their budget in 2027.