Medicare, Medicaid & what's changing

Medicare's Annual Enrollment Period runs October 15 through December 7, 2026. This is the main yearly window when anyone with Medicare can switch plans, change prescription drug coverage, or move between Original Medicare and Medicare Advantage. Changes take effect January 1, 2027.

If you do nothing, your current plan usually rolls over automatically. But plans change their costs, drug lists, and provider networks every year, so even if you're happy, it's worth a quick review to make sure your plan still fits. A medication that was covered last year may not be this year.

There's also a second, more limited window: Medicare Advantage Open Enrollment runs January 1 to March 31, but only for people already in an Advantage plan who want to switch or return to Original Medicare.

Source: Medicare.gov

For the first time, Medicare Part D caps what you pay out of pocket for covered prescriptions at $2,000 for the year. Once you hit that limit, you pay nothing more for covered drugs for the rest of the year.

This comes from the Inflation Reduction Act and is meaningful relief for anyone managing expensive medications, especially specialty drugs and biologics that used to cost far more. If you've been rationing a medication because of cost, this change is worth understanding.

Source: Medicare.gov

The standard Part B premium rose to $202.90 a month in 2026, up from $185 in 2025. The annual Part B deductible is now $283, up from $257.

Higher earners pay more than the standard premium, based on income. If you noticed your premium climb this year, this is why. It's a roughly 10% increase, which CMS attributes to rising healthcare prices and usage.

If this increase is a strain, you may qualify for help: Medicare Savings Programs and Extra Help can lower or cover Part B premiums and drug costs for people with limited income. It's worth checking.

Source: CMS — 2026 Medicare Premiums & Deductibles

Starting January 2027, work and community engagement requirements will apply to adults covered under Virginia's Medicaid Expansion (ages 19 to 64).

Importantly, this does not apply to everyone. It does not affect children, pregnant and postpartum individuals, adults with a disability, or people over 64. If you're on expansion coverage, now is the time to understand how this will work so you're not caught off guard when it takes effect.

If you're unsure whether this applies to you, or what you'd need to do to stay covered, that's exactly the kind of thing I can help you figure out.

Source: Cover Virginia — Adults 19 to 64

The single most common point of confusion, and it's an easy one to clear up:

Medicare is health coverage based on age. It's federal insurance mainly for people 65 and older (and some younger people with disabilities). It is not based on income. If you've worked and paid Medicare taxes, you've been paying into it your whole career.

Medicaid is health coverage based on income. It's a joint federal-and-state program for people with limited income, at any age. In Virginia it's called Cardinal Care. Unlike Medicare, there's often little or no monthly premium.

Some people qualify for both, which is called being "dual eligible." When that happens, Medicaid can help pay for costs Medicare doesn't cover, like premiums and copays. Many people who qualify for this never apply, and it can save thousands a year.

• Part A is hospital insurance. It's usually free if you (or a spouse) paid Medicare taxes for at least 10 years.
• Part B is medical insurance: doctor visits, outpatient care, and preventive services. It has a monthly premium.
• Part D is prescription drug coverage.
• Part C, also called Medicare Advantage, is a private all-in-one alternative that bundles A, B, and usually D into a single plan.

The big decision most people wrestle with during open enrollment is Original Medicare (A + B, often with a separate Part D) versus Medicare Advantage (Part C). Each has trade-offs in cost, flexibility, and provider choice, and the right answer depends entirely on your situation.

Virginia expanded Medicaid in 2019, so more working adults qualify than many people realize. Eligibility is based on your income compared to the federal poverty level (FPL):

• Adults 19 to 64: income up to about 138% of FPL (roughly $1,836/month for a single person, about $3,795/month for a family of four in 2026)
• Children: covered at higher income levels through Medicaid or FAMIS, with no asset test
• Pregnant individuals: covered up to about 148% of FPL, with 12 months of postpartum coverage
• Seniors & people with disabilities: follow different rules that include asset limits

These numbers shift a little each year and your exact situation changes the math, so the only way to know for sure is to apply for a full review. It's free, and applying costs you nothing if you don't qualify.

Source: Cover Virginia (CoverVA)