Why Your Health Insurance is Changing in 2026 (And How to Prepare)

Managing a chronic illness like lupus is already a full-time job. When you add the news that health insurance premiums are projected to spike significantly in 2026—with some ACA Marketplace plans seeing jumps as high as 26%—it’s natural to feel a sense of "medical sticker shock."

With the expiration of the enhanced premium tax credits and the implementation of new legislation, such as the One Big Beautiful Bill Act (OBBBA), the landscape of healthcare is shifting. The expected spike in 2026 healthcare premiums is being driven by a "perfect storm" of legislative changes, rising drug costs, and shifts in who stays insured.

While medical inflation happens every year, 2026 is seeing a much larger jump. For the lupus community, where specialist visits and biologics are a necessity, these changes require a proactive strategy.

Here is your roadmap for navigating the 2026 insurance increases.

1. Do the "Heavy User" Math

For many, the instinct is to pick the plan with the lowest monthly premium. However, for lupus patients who often hit their Maximum Out-of-Pocket (MOOP) every year, a "Gold" or "Silver" plan with a higher premium but a lower deductible and MOOP often ends up being cheaper in the long run.

• Calculate your 2025 spending: Look at your total pharmacy and specialist co-pays.

• The "Total Cost" Formula: $(Monthly Premium \times 12) + Maximum Out-of-Pocket$.

• Oregon Note: If you are in Oregon, our state-run marketplace may see slightly lower benchmark increases (around 17%) compared to the 30% jump expected in Healthcare.gov states.

2. Leverage the 2026 Medicare Part D Cap

If you are on Medicare, there is a major silver lining in 2026. Thanks to recent reforms, there is now a $2,000 annual cap on out-of-pocket prescription drug costs.

Pro Tip:  Look into the "Medicare Prescription Payment Plan." This new 2026 feature allows you to spread that $2,000 out into monthly installments rather than paying it all at once during a "lupus flare" early in the year.

3. Explore Direct Primary Care (DPC)

The OBBBA of 2026 introduced a game-changer: you can now use your Health Savings Account (HSA) to pay for Direct Primary Care memberships tax-free.

DPC practices charge a flat monthly fee for unlimited access to a primary doctor. This can be a lifesaver for lupus patients who need frequent monitoring or quick script refills without the $50+ co-pay for every "quick check-in."

4. Master the Medication "Paperwork"

Lupus medications like Benlysta or Saphnelo are costly. As premiums rise, insurance companies often tighten their "Formularies" (the list of drugs they cover).

• Check the 2026 Formulary: Before renewing, ensure your specific biologic is still on the "Preferred" list.

• Patient Assistance Programs (PAPs): If your drug is moved to a higher tier, go directly to the manufacturer's website. Organizations like HealthWell Foundation and the PAN Foundation often have specific funds for Systemic Lupus Erythematosus (SLE) to help cover premiums and co-pays.

5. Utilize State-Specific Advocacy

Don't navigate this alone. The Lupus Foundation of America and local Oregon chapters often release specific "Open Enrollment Guides" tailored to the current year's legislative changes.

Your Next Step...

Use this checklist when speaking to an insurance representative to ensure your 2026 coverage actually supports a life with lupus.

📉 The "Bottom Line" Financials

• What is my "True Cost" for the year? Ask the broker to calculate: (Monthly Premium x 12) + Maximum Out-of-Pocket. For lupus patients, you will likely hit the max; this number is more important than the monthly premium.

• Is this a "Standard" or "Non-Standard" plan? Under the new 2026 rules, some plans have much higher coinsurance (percentages) rather than flat copays.

• Are there still Premium Tax Credits available for my income level? With the 2026 changes, some income brackets that previously qualified for subsidies may no longer be eligible.

💊 The Medication Strategy

• Are my biologics (e.g., Benlysta, Saphnelo) on the 2026 Formulary? Formularies change every year. Do not assume your drug is still covered.

• What "Tier" is my medication in? If it moved from Tier 3 to Tier 4, your cost could jump from a flat $50 to 30% of the drug's total price.

• Does this plan allow for "Manufacturer Copay Cards" to count toward my deductible? (Some plans have "accumulator" programs that prevent this—ask specifically about this!)

🏥 The Care Team & Networks

• Is my Rheumatologist still in-network? Hospitals and provider groups are renegotiating contracts aggressively for 2026.

• Which lab is in-network? Lupus requires frequent blood work. If the plan uses Quest but your doctor only uses Labcorp, you could face massive "out-of-network" bills for routine tests.

• Does this plan require "Prior Authorization" for every specialist visit? Some 2026 HMOs have tightened "gatekeeper" rules.

🆕 2026 OBBBA & HSA Specifics

• Can I pair this plan with an HSA to pay for a Direct Primary Care (DPC) membership? Under OBBBA, you can now use tax-free HSA funds for DPC (up to $150/month). Ask if your specific plan is "HSA-Compatible."

• Is Telehealth covered "Pre-Deductible"? As of 2026, most HDHPs can now permanently cover your virtual visits before you even hit your deductible.

• Am I at risk for "Subsidy Repayment"? Ask about the new 2026 removal of the tax liability cap. If your income fluctuates, you need to know if you'll owe money back at tax time.

👵 Medicare-Specific (If applicable)

• How do I opt into the "Medicare Prescription Payment Plan"? This allows you to spread the $2,100 drug cap into monthly installments rather than paying it all in January.

• Are my vaccines covered at $0? (Confirming the 2026 "No-Cost Vaccine" rule for shingles or pneumonia shots).

Compiled By:

Kelli (Casas) Roseta

**All resources provided by this blog are for informational purposes only, not to replace the advice of a medical professional. Kelli encourages you to always contact your medical provider with any specific questions or concerns regarding your illness. All intellectual property and content on this site and in this blog are owned by morethanlupus.com. This includes materials protected by copyright, trademark, or patent laws. Copyright, More Than Lupus 2025.

Sources & Legislative & Government Resources:

• HealthCare.gov - 2026 HSA Options: Details on the new 2026 rules allowing all Bronze and Catastrophic plans to pair with Health Savings Accounts.

• Medicare.gov - Prescription Payment Plan: Official information on how to opt into monthly installments for your medications to avoid high upfront costs.

• KFF (Kaiser Family Foundation) - Health Reform: The gold standard for non-partisan analysis of how 2026 premium increases and subsidy expirations will impact individuals.

• Lupus Foundation of America - Insurance Guide: Offers a comprehensive toolkit for choosing plans and understanding "Step Therapy" (the "Fail First" rule).

• Lupus Research Alliance - Financial Resource Center: A directory of grants and emergency funds specifically for the lupus community.

If the 2026 rate hikes make your medications unaffordable, these foundations can often bridge the gap.

• PAN Foundation - Lupus Fund: Provides grants to help with out-of-pocket costs for lupus medications. (Note: You can sign up for "waitlist alerts" if the fund is temporarily closed).

• HealthWell Foundation: Another major provider of co-pay and premium assistance. They have specific funds for Systemic Lupus Erythematosus (SLE).

• NeedyMeds: A massive database where you can search by your specific medication name (e.g., Benlysta, Saphnelo, Plaquenil) to find manufacturer-specific discount cards.

• Oregon HealthCare.gov: The best place to check for state-specific subsidies and the status of Medicaid (OHP) redeterminations in 2026.

• 211info (Oregon & SW Washington): A local service that connects you with community-based financial assistance for medical bills and transport.