Open Enrollment for Practices: 6 Easy Steps Before January
Open enrollment for practices is the yearly check where you find out which patients changed health plans, so January claims go to the right payer under the right rules. A new plan can change the payer, your network status, the patient’s cost share and the benefits, and most changes start January 1. Our post on open enrollment changes for private practices covers what changes for eligibility and claims.
What open enrollment means for your practice
Open enrollment is the yearly window when people can join, drop or switch health plans. For a practice, it means some patients arrive in January with a new card, a new payer or a new cost share, and nobody tells you unless you ask. Open enrollment for practices is mostly front-desk work in November and December.
Private payers: Marketplace and employer plans
HealthCare.gov lists open enrollment for 2027 Marketplace coverage as November 1 to January 15. Plans chosen by December 15 start January 1, and plans chosen December 16 through January 15 start February 1 (HealthCare.gov dates and deadlines, checked 10/24/26). If your state runs its own marketplace, confirm its dates on the state site. Employer plans set their own windows, which HealthCare.gov’s open enrollment glossary entry notes may differ from the Marketplace, so ask patients rather than assume.
Medicare and Medicaid
Medicare Open Enrollment runs October 15 to December 7, and changes start January 1 (Medicare.gov, checked 10/24/26). People already in a Medicare Advantage Plan have a separate period from January 1 to March 31 to switch plans or return to Original Medicare (Medicare.gov, joining a plan), so a Medicare patient’s coverage can change in the first quarter too. Medicaid does not follow these windows. HealthCare.gov says people can apply for Medicaid at any time, and each state sets its own rules, so check your state Medicaid agency.
What changes when a patient switches plans
A plan change can touch four things that decide whether your claim pays: the payer, your network status, the patient’s cost share, and the benefit rules. Open enrollment for practices should cover all four before the first January session. The table shows what to look for.
| What can change | Why it matters | What to check |
|---|---|---|
| Payer and member ID | Claims sent to the old payer or ID are denied or lost | New card, front and back; payer name and ID; claims address |
| Network status | You may be in network with one plan and out of network with the next | Your status with the new plan before the first visit |
| Cost share | Last year’s copay may not apply | Copay, deductible, coinsurance, and what is left to meet |
| Benefits | Visit limits, prior authorization and telehealth rules differ by plan | Covered codes, limits, authorization, telehealth coverage |
Psychiatrists: verify medication-management evaluation and management (E/M) visits separately from psychotherapy add-on codes, because a plan may cost-share them differently.
Why January cost-share surprises happen
For open enrollment for practices, note that most deductibles reset at the start of the plan year, so the first sessions of a new year are often collected at the full allowed amount. The calendar year deductible resets on the plan’s date, which is on the benefits summary and is not always January 1. Quoting last year’s copay to a patient who is now on a deductible plan is how surprise balances start. Our guide to patient benefit verification lists the questions to ask.
How do I prepare my practice for open enrollment?
Start in November. Ask every active patient whether their plan is changing, collect any new card, and re-verify eligibility and benefits for dates of service on or after January 1. Flag anyone moving to a plan where you are out of network. That is open enrollment for practices in one sentence.
What to do Monday morning: 6 easy steps
- Ask. Add “Is your insurance changing on January 1?” to November appointment reminders and the intake form.
- Collect. Get a photo of the front and back of any new card and update the payer, member ID and group number in your system.
- Verify. Run insurance verification for the first January date of service: active coverage, plan year start, deductible met, copay or coinsurance, visit limits, authorization.
- Flag network status. Check whether you are in network with each new plan. If not, review in-network vs out-of-network credentialing and the steps for out-of-network billing.
- Update payer details. Confirm payer IDs and claims addresses for new plans. Our insurance companies contact directory is a starting point, and the payer’s own provider page is the final word.
- Script the balance conversation. Write two sentences staff can use: what the plan says the patient owes, and that it is an estimate until the claim is paid. If many patients move to a payer where you are not enrolled, that is a credentialing question for the new year.
What if a patient changes plans outside open enrollment?
It can happen, and open enrollment for practices does not cover it. HealthCare.gov says that after open enrollment ends, people can enroll in or change Marketplace plans only if they qualify for a Special Enrollment Period, such as after losing other coverage. A patient may therefore change plans mid-year. Treat any new insurance card as a trigger to verify again, whatever the month.
The short version: open enrollment for practices
Open enrollment for practices comes down to asking early and verifying before the first January visit. Collect new cards, check the payer, network status, cost share and benefits, and tell patients their share is an estimate until the claim is paid.
How MCM South helps
MCM South Medical Billing Service, LLC bills mental and behavioral health claims for psychotherapists and psychiatrists, including out-of-network claims. For open enrollment for practices, we also offer insurance verification and eligibility checks, so a plan change shows up before the claim goes out.
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FAQ
When is open enrollment?
It depends on the plan type. HealthCare.gov lists Marketplace open enrollment for 2027 coverage as November 1 to January 15, Medicare Open Enrollment runs October 15 to December 7, and employer plans set their own windows. Check the date for each patient’s plan type.
Do I need to re-verify every patient on January 1?
Not every patient changes plans, but re-verifying everyone you will see in January is the safest way to catch changes before you bill. Deductibles also reset, so your cost-share quote may change even when the plan does not.
Does open enrollment change Medicare billing?
It can. A patient who switches between Original Medicare and a Medicare Advantage Plan, or between Advantage plans, may have a different payer, network and rules starting January 1. Verify the new coverage before the first visit.
Can a patient change plans outside open enrollment?
Sometimes. HealthCare.gov says that after open enrollment ends, Marketplace changes need a Special Enrollment Period, for example after losing other coverage. Medicare Advantage members also have a January 1 to March 31 period. Re-verify whenever a patient hands you a new card.
What if a patient moves to a plan where I am out of network?
Tell the patient before the visit, explain the out-of-network cost share the plan reports, and follow your written financial policy. Ask the payer or your counsel if your contract or state rules raise a question.
Where MCM South works
MCM South Medical Billing Service, LLC works with psychotherapists and psychiatrists in our ten currently served states: Georgia, Massachusetts, Connecticut, Texas, Florida, New York, Colorado, Tennessee, North Carolina and Illinois. We serve solo and medium-size practices that bill mental and behavioral health. Founder Michael Williams has worked with insurance payers in all 50 states. Browse the state and regional billing guides for rules that vary by state, or see our billing services.
This post is operational guidance for billing, not legal advice. Rules change, so confirm with the payer or your counsel.
