OPEN ENROLLMENT ALPHABET SOUP: A RECIPE TO MAINTAIN YOUR SANITY
I am passionate about caring and advocating for my patients, my family, my community. This is an unprecedented time where our choices about our health and safety are at stake. Patients are frustrated, confused, in debt. Health care workers are both physically and mentally broken.
I have joined the Direct Primary Care (DPC) movement because I am tired of supporting the broken healthcare system. Instead, I want to support patients that want to take their care into their own hands, that see the benefit of having a trusted ally in their wellness, that see the benefit in having choice. Health care wasn’t always like this and it doesn’t have to be now- its time to imagine and demand something different.
It may feel like options have whittled down between one nauseatingly costly and restrictive health insurance plan or another. Most plans continue to increase in cost, cover less, and add layers of opaque ever-changing rules about how you actually access care. This system did not develop accidentally but rather as form of confusion-for-profit built into the system to benefit insurers and middle men. Even well-meaning reforms such as the Affordable Care Act of 2010 which expanded access to health insurance reinforced the role of private companies running wild within the health care system. Today, the current government stalemate has exposed how vulnerable we are in our dependence on this system.
Open enrollment is here- make choice your superpower. Explore alternatives to the goliath health insurers. Join the DPC movement. Advocate for more flexible options through your employer, like Health Reimbursement Arrangements. Support Massachusetts House Bill H1343 that prohibits out of network-based payment denials. Support your immigrant family and friends in maintaining their access to care. Connect with Health Care for All, a nonprofit organization helping patients understand and access health coverage in Massachusetts.
DPC can be a steady hand navigating this time. I’ve created the guide below in attempt to support your sanity in the process of finding affordable healthcare for you and your family. Feel free to share this information widely.
Be well!
Dr Goldburt
Flowfamilymedicine.com
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Options outside the box of typical managed care:
I am partial to Direct Primary Care (DPC) to meet your family’s primary care needs. It is a subscription-based membership model where you pay a flat monthly fee to have direct access to your doctor. The unique payment structure is clear, transparent and affordable as it eliminates the administrative burdens of insurance that typically interfere with patient care and accessibility . DPC is not insurance; it does not quality for minimal essential coverage per the ACA regulations and is ideally paired with some form of major medical coverage.
Some people elect to work with a health ministry. Health Care Sharing Ministries allow people to come together as a community based on faith or common values to share each others health care expenses. When members go to the doctor, hospital, or incur a medical cost, they submit the bill to their community, through their ministry. Expenses that meet the ministry’s guidelines are shared by the community and payment is made to the family or directly to the doctor.
An indemnity health plan will reimburse an enrollee for a portion of their healthcare costs, regardless of what medical provider the member uses or how much the provider bills. The plan pays a pre-determined percentage of the reasonable and customary charges for a given service, and the policyholder pays the rest. Indemnity plans, sometimes referred to as “traditional” or “conventional” plans, dominated the health coverage landscape before the rise of HMOs, PPOs, and other managed care plans in the 1980s and 90s. Fixed indemnity plans are not regulated by the ACA, so they don't have to cover the essential health benefits or pre-existing conditions.
Open Enrollment through employers:
2026 Open Enrollment: variable
Get questions about your insurance options and alternatives by speaking directly to your HR/ Benefits Manager
Read the fine print! For a majority of people, more than 75% of their healthcare costs in the next year are predictable based on their current health needs. Take a look at your family’s utilization of care for this year and compare it the cost of the annual premium plus out of pocket deductibles (out of pocket costs until insurance kicks in coverage) for each plan. How much money did your family leave on the table this year?
Consider a High Deductible Health Care (HDHP) plan plus a Health Savings Account (HSA). Traditional health plans tend to have much higher premiums (monthly cost), which means more money out of each paycheck. Do the math. You may find that the annual premium savings of an HDHP offsets the comparatively higher deductible. At minimum, more take-home pay can potentially make it easier for you to plan for and to cover that higher deductible.
Then, choose an HSA and create long-term health savings by setting aside pre-tax money for medical expenses. They’re widely considered one of the most powerful long-term savings tools thanks to a triple tax advantage:
Tax-free contributions: Pre-tax dollars lower your taxable income.
Tax-free growth: Interest and investment earnings aren’t taxed.
Tax-free withdrawals: Money used for qualified medical expenses is tax-free.
Then, you can use that money tax-free to pay for thousands of qualified medical expenses. One exciting development is that as of January 1, 2026, you will be able to use HSA funds to pay DPC subscription fees, up to $150/month.
HSA funds never expire. They stay in your account even if you change employers, health plans, or retire. In many cases, current employers may offer a contribution, usually depositing that contribution into your HSA on the first day of the new plan year. Some offer an HSA contribution match.
See if your employer offers a Health Reimbursement Arrangement (HRA). You can purchase insurance or an indemnity plan on the free market. The employee pays for health care expenses or individual health insurance premiums, and the employer reimburses them. The simplicity of this arrangement allows the employee to take control of their healthcare costs by choosing where to spend their dollars and price shopping around to find the best value for the healthcare they need.
Open enrollment through Massachusetts Health Connector
2026 Open Enrollment period: November 1, 2025 - January 23, 2026.
(December 23, 2025: Last day to shop and enroll in health insurance, dental insurance, or both, that starts January 1, 2026)
Get help with enrollment: https://www.mahealthconnector.org/help-center/in-person-help or by calling 1-877-MA-ENROLL (1-877-623-6765), or TTY: 711.
Households earning above 400% of the federal poverty level — about $62,600 for a single person or $128,400 for a family of four — will no longer qualify for heavily subsidized ConnectorCare coverage starting on Jan. 1. Instead, those members will need to "explore unsubsidized health plan options, which may result in higher out-of-pocket costs," the Connector says.
Around 36,000 Health Connector members who are noncitizens but legally present here will likely be impacted as they will lose eligibility for heavily subsidized ConnectorCare coverage starting Jan. 1, regardless of whether enhanced premiums tax credits are extended.
Open enrollment for MassHealth plans
2026 Open Enrollment period: November 1, 2025 to December 23, 2025
Get help with enrollment: https://masshealthchoices.com/en/compare or call 1-800-841-2900 (TDD/TTY:711).
MassHealth managed plans have specific provider, hospital, and service areas. Currently, all MassHealth plans other than Medicaid Standard require you to have a PCP in-network with the plan that you choose, and that PCP is responsible for coordinating all your specialty care.
For patients who qualify for both MassHealth and Medicare, they may be required to sign up for the One Care program.
Open Enrollment for Medicare:
2026 Open Enrollment period: October 15 to December 7
Get help with enrollment: SHINE program: Shine program. You can find a SHINE counselor near you by calling MassOptions at 1-800-243-4636
You’ll use Medicare differently depending on whether you pick original coverage or Medicare Advantage. https://www.medicareinteractive.org/understanding-medicare
By law, original Medicare and Medicare Advantage plans both must provide coverage for the same medical services, including blood work; diagnostic tests, such as X-rays and other scans; doctor visits; hospitalizations; and outpatient surgery. Here’s a comparison of how each works.
With original Medicare: You have to purchase parts A,B,D separately. You can choose any primary care doctor or specialist who accepts Medicare. You don’t need referrals to see any provider, and you don’t have to worry about your doctor leaving a plan’s network or your doctor is retiring. Original Medicare won’t pay for routine dental, hearing, and vision care, but you can purchase Medigap supplements cover those services.
Medicare Advantage: Similar to employer coverage, these plans are managed by private insurance companies and encompass all coverage in one plan, within networks that limit you to their doctors and hospitals. They also do not provide nationwide coverage. In 2025 the cap for out of pocket costs was up to $8,550 in network, and many doctors and hospitals may be out of network and not covered at all. There is also a higher rate of prior authorizations and claim denials, delaying timely care. Most Advantage plans provide some dental, hearing and vision care. Some even extend coverage to gym memberships, over-the-counter medications and transportation to the doctor’s office.
If you are concerned that you cannot afford Medicare coverage, you can see if you qualify for the Medicare Savings Program through Mass.gov.