What Providers and Facilities Should Know About This Year’s Insurance Open Enrollment Period

Each fall, the health insurance marketplace enters one of its most consequential times of the year, Open Enrollment. While the headlines often focus on what these changes mean for consumers, it’s equally vital for healthcare providers and facilities to understand how shifts in insurance plans, premiums, and pre-authorization rules can directly affect their bottom line and reimbursement cycles.

This year’s Open Enrollment period, running from November 1, 2025, through January 15, 2026, comes at a pivotal time. With ongoing changes under the Affordable Care Act (ACA) framework and new pressures on commercial insurers to control costs, providers must be proactive in navigating the evolving landscape.

Rising Premiums and Narrower Networks: What That Means for Reimbursement

According to recent projections from the Centers for Medicare & Medicaid Services (CMS), average ACA plan premiums are expected to rise between 6% and 9% nationwide, with some Florida markets seeing double-digit increases. While this may seem like a consumer issue, higher premiums often push patients toward lower-cost plans with narrower networks or higher deductibles.

For hospitals, rehabilitation facilities, and outpatient providers, this translates into greater variability in patient coverage. More patients may arrive with high-deductible health plans (HDHPs) or exchange-based products that reimburse at lower rates. Facilities must carefully verify eligibility and network participation to avoid providing services under out-of-network terms.

In short, the financial exposure doesn’t just fall on patients, it often lands squarely on providers when insurers deny coverage or underpay claims based on network status.

The Evolving Role of Pre-Authorizations

One of the most significant trends emerging from insurers this year is the tightening of pre-authorization requirements, particularly in the wake of recent legal and regulatory scrutiny around medical necessity determinations.

As federal policymakers debate potential adjustments to the ACA and utilization management rules, insurers are proactively revising their prior authorization protocols to reduce unnecessary spending. Unfortunately, these changes often mean increased administrative burdens for providers; especially in fields such as rehabilitation, physical therapy, and behavioral health, where the necessity of ongoing care can be difficult to justify in short increments.

Providers should take the time now to review payer policy updates and educate billing teams about revised requirements. A small oversight, such as missing an updated authorization code or failing to document the specific functional goals of therapy, can lead to unnecessary denials or recoupments.

The Impact of Potential ACA Reforms

While the ACA remains in effect, certain proposed changes, particularly those related to cost-sharing subsidies and coverage mandates, could influence both the composition of marketplace plans and the patient mix that providers encounter in 2026.

If subsidies are reduced or coverage mandates loosened, it’s likely that more patients will shift toward non-ACA compliant plans or short-term limited-duration coverage. These plans often lack key consumer protections, such as guaranteed essential health benefits or limits on annual out-of-pocket costs.

From a reimbursement standpoint, these alternative policies can pose significant challenges. They frequently include ambiguous coverage exclusions, vague claims processing timelines, and limited appeal rights, leaving providers with little recourse in the event of underpayment or denial. Hospitals and physician groups should train front-end registration and financial counseling staff to identify and document plan types at intake, setting realistic expectations for patients and avoiding surprises later in the revenue cycle.

Preparing for the Post-Enrollment Claims Cycle

Once the Open Enrollment dust settles, providers will likely experience a surge of patients presenting with new insurance cards, updated policy numbers, and revised benefit structures. To minimize disruption during this transition, facilities should take proactive steps such as updating patient intake protocols to ensure accurate insurance information is captured at every encounter, and reverifying authorizations for ongoing treatment plans that span multiple coverage periods. It is equally important to monitor payer bulletins for any midyear changes to medical policies or reimbursement methodologies, and to educate patients about potential coverage modifications, encouraging them to verify their benefits early to avoid care delays. By implementing these operational adjustments, providers can significantly reduce claim rejections and maintain stronger cash flow during the critical first quarter of the new plan year.

How Legal Counsel Can Help

Given the complexity of today’s healthcare reimbursement environment, working closely with counsel experienced in payer disputes and regulatory compliance can provide a strategic advantage. From challenging unlawful denials to negotiating payer contracts, a proactive legal strategy helps providers safeguard their revenue while maintaining compliance with evolving state and federal rules.

At Abril Law, we work alongside hospitals, physician groups, and rehabilitation facilities throughout South Florida to navigate these challenges, protect reimbursements, and ensure providers are paid fairly for the care they deliver.

Conclusion

Open Enrollment is more than a patient decision period, it’s a time for providers to assess their payer mix, strengthen their compliance practices, and prepare for the policy shifts ahead. Understanding the ripple effects of ACA changes, premium adjustments, and pre-authorization trends can make the difference between smooth reimbursement operations and costly denials in 2026.

Article Originally Posted in the December 2025 Issue of the South Florida Hospital News and Healthcare Report: https://southfloridahospitalnews.com/what-providers-and-facilities-should-know-about-this-years-insurance-open-enrollment-period/