2026 Healthcare Costs: What Your Patients Need to Know Now

2026 Healthcare Costs: What Your Patients Need to Know Now

January 2026 brings major healthcare cost changes for patients. The enhanced ACA premium tax credits expired on December 31, 2025. Congress left Washington without extending them.[1] An estimated 22 million marketplace enrollees now face premium increases averaging 114%.[2] Medicare Part D's out-of-pocket cap rises to $2,100[3], and Medicaid work requirements take effect January 2027.[4] Practices need to prepare patients now for these affordability challenges.

ACA Enhanced Premium Tax Credits: What Just Happened

Congress recessed for the holidays on December 18, 2025 without extending the enhanced ACA premium tax credits. [1] The subsidies expired on December 31, 2025. Millions of marketplace enrollees are now facing significantly higher premiums for 2026 coverage.

The enhanced premium tax credits, first introduced in the American Rescue Plan Act of 2021 and extended through the Inflation Reduction Act, made ACA marketplace coverage more affordable for over 22 million Americans.[2] Without extension, enrollees will experience:

  • Average premium increase of 114%: Annual out-of-pocket premium payments rising from an average of $888 to $1,904[2]
  • Return of the subsidy cliff: Anyone earning over 400% of the federal poverty level (~$62,600 for an individual) loses all premium assistance[5]
  • Devastating impact on older enrollees: A 60-year-old couple earning $85,000 could see annual premiums jump from ~$7,225 to approximately $29,825[6]
  • Coverage losses: The Urban Institute estimates approximately 4.8 million people will become uninsured[7]

What this means for your patients: Patients on ACA marketplace plans may be experiencing sticker shock when they see their 2026 premiums. Some may consider dropping coverage, which could lead to delayed care, unpaid medical bills, and worse health outcomes. Practices should proactively reach out to affected patients about financial assistance options and payment plans.

Medicare Part D: Good News with a Small Adjustment

For Medicare beneficiaries, the news is better. The Inflation Reduction Act's Part D redesign continues to protect patients from catastrophic drug costs. The annual out-of-pocket cap increases slightly from $2,000 in 2025 to $2,100 in 2026.[3] Once patients reach this cap, their plan covers 100% of covered drug costs for the rest of the year.[8]

Key Medicare Part D Changes for 2026:

Change Details
Out-of-pocket cap $2,100 (up from $2,000) [3]
Maximum deductible $615 (up from $590) [8]
Prescription Payment Plan (M3P) Auto-renews for 2026 [9]
Negotiated drug prices 10 drugs at reduced prices effective Jan 1 [10]
Catastrophic coverage $0 cost-sharing after cap is reached [8]

Medicare Prescription Payment Plan (M3P): Patients who enrolled in this program in 2025 are automatically renewed for 2026 unless they opt out.[9] This program allows patients to spread out-of-pocket costs across the year rather than paying large amounts upfront at the pharmacy. This is particularly valuable for patients on multiple high-cost medications who may hit the $2,100 cap early in the year.

First negotiated drug prices take effect: Medicare's first-ever negotiated drug prices become effective January 1, 2026 for 10 high-cost medications including Stelara, Enbrel, Januvia, and Eliquis.[10] CMS estimates Medicare beneficiaries will save $1.5 billion in out-of-pocket costs.[10] Learn more about 2026 specialty drug pricing changes for Stelara, Enbrel, and other infusion medications.

Medicaid Work Requirements: Preparing for January 2027

The One Big Beautiful Bill Act (H.R. 1), signed into law on July 4, 2025, introduces the first-ever federal Medicaid work requirements.[4] Starting January 1, 2027, adults ages 19-64 in Medicaid expansion populations must document 80 hours per month of work, job training, education, or community service (or qualify for an exemption) to maintain coverage.[11]

Key Implementation Timeline:

  • June 2026: HHS must issue implementation guidance to states[11]
  • June-August 2026: States begin required outreach to notify enrollees[11]
  • December 31, 2026: States must have work requirements in place (or have received an extension)[4]
  • January 1, 2027: Work requirements take effect for applications and renewals[4]

Who is exempt: Pregnant individuals, those receiving disability benefits, full-time students, caregivers of children under 13 or disabled dependents, and those with documented health conditions that prevent work.[12]

Projected impact: The Congressional Budget Office estimates work requirements will cause 5.3 million adults to lose Medicaid coverage by 2034 and reduce federal Medicaid spending by $326 billion over 10 years.[4] Prior experience in Arkansas showed that 18,000 people lost coverage in less than a year, primarily due to confusion about reporting requirements, not failure to meet work criteria.[13]

ACA Out-of-Pocket Maximums Rise in 2026

Beyond premium increases, ACA marketplace enrollees also face higher out-of-pocket maximums in 2026. The maximum annual cost-sharing limits for marketplace plans are:[14]

  • Individual coverage: $10,600 (up from $9,200 in 2025)
  • Family coverage: $21,200 (up from $18,400 in 2025)

This represents approximately a 15% increase in maximum out-of-pocket exposure. Combined with the loss of enhanced premium subsidies, patients on marketplace plans face a double hit to their healthcare budgets.

What Your Practice Should Do Now

  1. Identify affected patients proactively. Patients on ACA marketplace plans, especially those over 50 or with incomes above 400% FPL, are most at risk of coverage disruption. Reach out before they miss appointments or delay care.
  1. Update financial counseling. Train front-office staff on the new numbers: $2,100 Medicare Part D cap, $10,600 ACA out-of-pocket maximum, and the impact of lost ACA subsidies.
  1. Connect patients with assistance programs. Manufacturer copay assistance, patient assistance programs (PAPs), and state pharmaceutical assistance programs remain available. Proactive enrollment can prevent treatment interruptions. See how in-office infusion improves patient access and reduces treatment barriers.
  1. Review Medicare patients on negotiated drugs. Patients taking Stelara, Enbrel, Januvia, Jardiance, Eliquis, or other negotiated drugs may see significant savings starting January 1.
  1. Prepare for Medicaid transitions. Some patients losing ACA coverage may qualify for Medicaid. Others on Medicaid will need to prepare for work requirements in 2027. Help patients understand their options now.

How OnePulse Connect Helps Your Practice Navigate 2026

OnePulse Connect provides integrated solutions to help practices and patients navigate these affordability challenges:

  • Benefits investigation and financial assistance: Care coordinators identify coverage options and connect patients with copay assistance and PAPs before affordability becomes a barrier to care
  • Medical vs. pharmacy benefit optimization: For patients on multiple medications, determining whether treatments should be covered under Medicare Part B (medical) or Part D (pharmacy) can significantly impact out-of-pocket costs
  • In-office infusion and dispensing: OnePulse Connect In-Office Infusion and Medically Integrated Dispensing help practices capture revenue while potentially reducing patient costs through streamlined copay assistance enrollment

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Learn More About OnePulse Connect

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About Elevate Health Technologies

Elevate Health Technologies is committed to making healthcare better for everyone. We collaborate with healthcare providers, patients, pharmaceutical manufacturers, and payers to deliver innovative technologies that truly make a difference. OnePulse Connect empowers healthcare practices by optimizing efficiency and streamlining care, whether through buy-and-bill management, inventory tracking, medically integrated dispensing, or in-office infusion services.

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References

[1] Zanona, M., Grayer, A., & Raju, M. "Congress leaves town until 2026, letting enhanced Obamacare tax credits expire." CNN Politics. December 19, 2025. https://www.cnn.com/2025/12/19/politics/congress-obamacare-subsidies-expiring

[2] Kaiser Family Foundation. "ACA Marketplace Premium Payments Would More than Double on Average Next Year if Enhanced Premium Tax Credits Expire." KFF.org. September 30, 2025. https://www.kff.org/affordable-care-act/aca-marketplace-premium-payments-would-more-than-double-on-average-next-year-if-enhanced-premium-tax-credits-expire/

[3] Centers for Medicare & Medicaid Services. "Final CY 2026 Part D Redesign Program Instructions." CMS.gov. April 7, 2025. https://www.cms.gov/newsroom/fact-sheets/final-cy-2026-part-d-redesign-program-instructions

[4] Kaiser Family Foundation. "A Closer Look at the Work Requirement Provisions in the 2025 Federal Budget Reconciliation Law." KFF.org. September 29, 2025. https://www.kff.org/medicaid/a-closer-look-at-the-work-requirement-provisions-in-the-2025-federal-budget-reconciliation-law/

[5] Center on Budget and Policy Priorities. "Ask an Expert: Enhanced Premium Tax Credit (PTC) Expiration." CBPP.org. October 22, 2025. https://www.cbpp.org/blog/ask-an-expert-enhanced-premium-tax-credit-ptc-expiration

[6] Kaiser Family Foundation. "Premium Payments if Enhanced Premium Tax Credits Expire." KFF.org. September 19, 2025. https://www.kff.org/affordable-care-act/premium-payments-if-enhanced-premium-tax-credits-expire/

[7] Commonwealth Fund. "Expiring ACA Premium Tax Credits Could Lead to Nearly 340,000 Jobs Lost Across the U.S. in 2026." CommonwealthFund.org. October 16, 2025. https://www.commonwealthfund.org/publications/issue-briefs/2025/oct/expiring-premium-tax-credits-lead-340000-jobs-lost-2026

[8] AARP. "3 Prescription Drug Changes Coming to Medicare in 2026." AARP.org. December 18, 2025. https://www.aarp.org/medicare/future-medicare-drug-payment-changes-2026/

[9] HealthDirect. "Did You Know? 2026 Medicare Part-D Overview." HDRxServices.com. October 20, 2025. https://www.hdrxservices.com/did-you-know-2026-medicare-part-d-overview/

[10] Kaiser Family Foundation. "FAQs about the Inflation Reduction Act's Medicare Drug Price Negotiation Program." KFF.org. August 9, 2025. https://www.kff.org/medicare/faqs-about-the-inflation-reduction-acts-medicare-drug-price-negotiation-program/

[11] Center for Health Care Strategies. "A Summary of Federal Medicaid Work Requirements." CHCS.org. October 1, 2025. https://www.chcs.org/resource/a-summary-of-national-medicaid-work-requirements/

[12] AJMC. "Medicaid Work Requirements Set to Leave Millions Without Insurance." AJMC.com. December 21, 2025. https://www.ajmc.com/view/medicaid-work-requirements-set-to-leave-millions-without-insurance

[13] Commonwealth Fund. "Work Requirements for Medicaid Enrollees." CommonwealthFund.org. September 30, 2025. https://www.commonwealthfund.org/publications/explainer/2025/sep/work-requirements-medicaid-enrollees

[14] HealthCare.gov. "Out-of-pocket maximum/limit - Glossary." HealthCare.gov. Accessed December 2025. https://www.healthcare.gov/glossary/out-of-pocket-maximum-limit/

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