A client of mine got hit with a surprise $600 bill last spring because she missed a subsidy change. That kinda thing is set to become a lot more common in 2026.

Health insurance 2026 is shaping up to be a truly disruptive year, and not in a good way. Several temporary protections are expiring, Medicare costs are rising, and the out-of-pocket limit on individual plans just went up again. Most of these shifts won’t announce themselves. They’ll quietly appear on your Explanation of Benefits months after you’ve made your enrollment decision.

So, here’s what’s changing and what I’d recommend doing about each one.

Cost Changes in 2026

The biggest shock for ACA enrollees is the premium tax credit cliff coming back. Enhanced subsidies from 2021 were extended through 2025, but Congress hasn’t moved to extend them again. If they expire as expected, a 40-year-old making $60,000 might see their monthly premium surge by $200 or more, depending on their state. That’s not pocket change.

On the Medicare side, Part B premiums are climbing to $185 per month in 2026, up from $174.70. That’s around an extra $122 per year for most beneficiaries. A bright spot is Medicare Part D, which is getting a positive change: the $2,000 annual out-of-pocket cap on prescription drugs kicks in this year. If you’re on pricey maintenance meds, you’ll feel that, especially if you were hitting the catastrophic phase before.

For individual market plans, the out-of-pocket maximum increases to $9,200 for a single person. That’s a slight bump from $9,100. It’s not a massive change, but it adds onto those higher premiums. Benchmark silver plan premiums are running 4 to 6 percent above last year’s levels in most areas, roughly double the increase from 2023 to 2024.

Changes in Coverage Rules

CMS is proposing rules that would require most ACA-compliant plans to cover GLP-1 drugs, including semaglutide medications like Ozempic and Wegovy, for obesity treatment and not just diabetes. This rule isn’t final as of early 2025, but if it goes through, it’d mark a significant coverage expansion. Insurers are already factoring this into pricing, helping to explain that 4 to 6 percent benchmark bump.

Worth noting: even if this rule solidifies, plans can still impose prior authorization. In my experience, many folks think “covered” means it’s easy to access. Usually, that’s not the case, especially during the first year a new benefit comes out.

Medicare Advantage plans are also tightening prior authorization under updated CMS oversight. The agency’s been cracking down on excessive denials, so theoretically, approvals should get faster. But I’d still expect some delays if you need anything beyond routine care. Keep that in mind and document everything.

Choosing a Plan This Year

Open enrollment for ACA marketplace plans runs from November 1 to January 15. That January 15 deadline is crucial: miss it, and you’ll need a qualifying life event to enroll until next fall. Meanwhile, Medicare’s Annual Election Period runs from October 15 to December 7, a different time frame most people mix up with ACA dates.

Given the subsidy cliff, the most important thing ACA enrollees can do is check their actual subsidy eligibility in October instead of just assuming last year’s figure still applies. Healthcare.gov has an updated estimator that’s worth using before plans go live on November 1. If those enhanced credits do expire, you might want to consider dropping to a lower metal tier. Just keep in mind you’d be trading lower premiums for higher cost-sharing, so it’s a trade-off worth calculating against your expected usage.

If you’re on Medicare, compare Part D plans every year. The $2,000 cap changes the calculations on what plan is cheapest based on your specific prescriptions. Sometimes, a plan with a higher premium will end up being the best choice if your formulary costs are high. Use the Medicare Plan Finder with your actual drug list, not just a generic estimate.

• Check your subsidy estimate in October.
• Compare drug formularies on Part D plans, not just premiums.
• Verify that your preferred providers are still in-network for 2026.
• Set a January 15 reminder if you’re in the ACA marketplace.

What to Do Before November

Health insurance 2026 decisions made without thought could cost some people hundreds of dollars. The subsidy expiration could make last year’s plan unaffordable, and the benchmark premium increase means even subsidized plans will eat up more of your budget. Don’t just rely on auto-renewal to put you in the right spot.

Pull your explanation of benefits from this year, look at what you actually spent compared to your expectations, and use that as your baseline. If you stayed well under the deductible, a higher-deductible plan could save you premium money. If you hit the out-of-pocket max, it’s likely worth the cost of a richer plan. That kind of personal math leads to a good enrollment decision and only takes 30 minutes to work through.

FAQs

Will ACA subsidies continue in 2026?

The enhanced premium tax credits are set to expire after 2025, which means many enrollees may face significantly higher premiums starting in 2026 unless Congress takes action.

What is the Medicare out-of-pocket cap in 2026?

The $2,000 annual out-of-pocket cap for Medicare Part D takes full effect in 2026, limiting how much beneficiaries will pay for covered prescription drugs each year.

When does 2026 open enrollment start?

Open enrollment for ACA marketplace plans runs from November 1, 2025, through January 15, 2026. Meanwhile, Medicare’s Annual Election Period is October 15 to December 7, 2025.