Open Enrollment and Your Practice: What to Do Before January
Open enrollment is the yearly window when people can pick a new health plan or change their current one. For a therapist or psychiatrist, it matters because a client’s new plan can change who pays, how much they pay per session, and whether you are in network, often starting January 1.
This guide covers private insurance (employer and Marketplace plans) and Medicare. It explains what changes on January 1 and what to do now so claims and balances stay clean. It is operational billing guidance for psychotherapists and psychiatrists, not legal advice. For more, see our mental health billing resources.
What is open enrollment, and why should a practice care?
Open enrollment is a set period each year when people can enroll in or change health coverage. The dates and rules depend on the type of plan, so private insurance and Medicare are explained separately below.
Private insurance: employer and Marketplace plans
- Employer plans: each employer sets its own window, often in the fall. Ask clients, or check the notices they bring in.
- Marketplace: open enrollment starts November 1, and you enroll by December 15 for coverage that starts January 1 (source: HealthCare.gov, checked 10/21/26). See our private insurance billing guides for payer-specific help.
Medicare
Medicare Open Enrollment runs October 15 to December 7. During that time, people can join, drop, or switch Medicare Advantage plans, or switch between Original Medicare and a Medicare Advantage plan. The changes take effect January 1 of the following year (source: Medicare.gov, checked 10/21/26).
Medicaid follows different rules and is not covered in this post. Do not assume one date fits every client.
What changes for your practice when a client changes plans?
Four things can change, and each one touches your claims.
- The payer. A new insurance company means new eligibility, a new member ID, and a new claims address. Medicare Advantage plans are generally offered by private companies that contract with Medicare, so a client who switches to one is now covered by a private plan with its own rules. Check that plan’s claims address and requirements.
- Network status. You may be in network with the old plan and out of network with the new one. See In-Network vs Out-of-Network for what that means for payment, Credentialing & Network Status for how to get in network, and our credentialing service page. If a client is out of network with you, read our guide to out-of-network therapy billing.
- Cost sharing. A client may move from a copayment plan (a flat amount per visit) to a deductible plan (the client pays the allowed amount until the deductible is met), or the reverse. Coinsurance is the percentage the client pays after that. Our Billing Terms Glossary defines each term.
- Benefits. Visit limits, prior authorization rules, and telehealth coverage can differ from plan to plan.
A deductible usually resets with the plan year, and the plan year is not always the calendar year. Check each client’s plan, and check Medicare cost sharing for the new year on Medicare.gov.
Why do deductible plans change what you collect?
On a deductible plan, a client often pays more per session early in the plan year, then less after the deductible is met. If you still quote last year’s copay, the client gets a surprise bill and your balance ages. Verify the new plan before the first January session and quote the real number. Our private practice management guides cover cash flow and billing metrics.
What should a practice do before January? (Monday morning list)
- Ask every active client, at their next visit, whether their insurance is changing for the new year, including Medicare clients who may switch plans.
- Collect new card images (front and back) and update the demographic and insurance fields in your system.
- Verify eligibility and benefits for each client on the new plan. Confirm the deductible, copay or coinsurance, out-of-network benefits, and visit limits.
- Flag clients who are now out of network with you, and tell them plainly what that means for their costs.
- Update your payer list and claims addresses. The Insurance Companies Contact page helps.
- Set a short script for your front desk about balances under a new plan.
How does MCM South help with insurance verification in January?
MCM South Medical Billing Service, LLC works only in mental and behavioral health, with psychotherapists and psychiatrists. As a service, MCM South verifies insurance for all active clients at the beginning of January. That catches plan changes, new payers, and new cost sharing before claims go out, so a denial for an inactive policy or a wrong payer is less likely to be the first sign. Get a Free Quote to ask how it would work for your practice.
Frequently asked questions
When is open enrollment for health insurance?
It depends on the plan. Medicare Open Enrollment runs October 15 to December 7. Marketplace open enrollment starts November 1, and you enroll by December 15 for January 1 coverage. Employers set their own dates.
Does a new plan on January 1 mean I must re-verify every client?
Not every client changes plans, but you will not know which ones did unless you check. Verifying every active client at the start of the year is the safest way to catch changes before you bill.
What is the difference between a copayment and a deductible plan?
A copayment plan charges a flat amount per visit. A deductible plan has the client pay the allowed amount until the deductible is met. Coinsurance is the percentage the client pays after that.
Can a client’s deductible reset on a date other than January 1?
Yes. The deductible resets with the plan year, and some plans start their year on a date other than January 1. Verify the plan year for each client.
Does open enrollment change how I bill Medicare clients?
It can. If a client switches from Original Medicare to a Medicare Advantage plan, or between Medicare Advantage plans, the new coverage starts January 1 and that plan’s network and rules apply. Verify before the first visit of the year.
Where MCM South works
MCM South serves practices in our ten currently served states: Georgia, Massachusetts, Connecticut, Texas, Florida, New York, Colorado, Tennessee, North Carolina, and Illinois. Open enrollment rules and plan details vary by plan type and by state, so check each client’s plan.
