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Learn how we can advance patient outcomes with innovative technology solutions
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As 2025 draws to a close, healthcare practices face an urgent challenge: preparing patients for significant financial changes coming in 2026. From Medicare Part D adjustments to potential ACA marketplace disruptions, these changes will impact millions of Americans' ability to afford care.
Here's some good news first: the Medicare Part D donut hole is gone. The Inflation Reduction Act eliminated this coverage gap in 2025, dropping the out-of-pocket maximum from over $8,000 down to $2,000.1 That's a massive improvement for seniors on multiple medications.
The small catch? That cap increases to $2,100 in 2026.2 While this is still dramatically better than previous years, patients taking 8 to 10 medications monthly (common for those receiving infusion therapy) need to understand that all their Part D medications count toward that maximum. This means many will hit the cap in the first quarter of the year.
The new Medicare Prescription Payment Plan (M3P) offers relief by letting patients spread their out-of-pocket costs across the year instead of paying large amounts upfront.3 Patients who enrolled in 2025 will be automatically renewed for 2026.
If Congress doesn't act, enhanced premium tax credits expire December 31, 2025. For 7 million marketplace enrollees, premiums could increase by an average of 114%.4 A 60-year-old couple earning $82,000 annually could see their premiums jump from $984 to $2,831 per month.5
The subsidy cliff also returns: anyone earning over 400% of the federal poverty level loses all premium assistance. Plus, out-of-pocket maximums increase to $10,600 for individuals in 2026.6
With work requirements potentially starting in January 2027 and ongoing eligibility redeterminations, 10 to 15 million people could lose Medicaid coverage over the next decade.7 Many will need to transition to marketplace plans, making enrollment assistance critical.
The early months of 2026 will be especially challenging. Patients with expensive medications often hit their out-of-pocket maximums in January and February. Without preparation, they may face:
OnePulse Connect provides integrated solutions that address these exact challenges:
One Pulse Connect Care Coordinators conduct comprehensive benefits investigations to identify coverage options and connect patients with copay assistance programs and patient assistance programs (PAPs). This proactive approach prevents treatment delays caused by affordability concerns.
This is especially important now with the 2026 changes. Since patients taking 8 to 10 medications monthly may hit the $2,100 out-of-pocket maximum early in the year, OnePulse Connect helps assess their total medication burden across all prescriptions. The platform also considers whether treatments should be covered under Medicare Part B (medical benefit) or Part D (pharmacy benefit), as this choice can significantly impact out-of-pocket costs.
OnePulse Connect In-Office Dispensing and In-Office Infusion is a win-win for healthcare practices and patients. Practices take advantage of increased revenue and efficiencies- patients benefit from lower potential costs with assistance to navigate complex copay programs.
Right Now:
By December 31, 2025:
Healthcare affordability will dominate 2026. Practices that prepare now can protect their patients from financial shock while maintaining continuity of care. The tools exist to help patients navigate these changes. But integrated platforms that combine benefits investigation, in-office dispensing, infusion management, and financial assistance enrollment can help bridge the affordability gap. The key is being proactive: start preparing now so your patients don't face delays in critical care.
Learn more about OnePulse Connect’s innovative solutions here.
About Elevate Health Technologies
Elevate Health Technologies is committed to making healthcare better for everyone. We collaborate with healthcare providers, patients, pharmaceutical manufacturers, and payors 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.
Visit www.elevateht.com to learn more.
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References
[1] medicareresources.org. Medicare Part D Coverage Gap (Donut Hole). 2025. https://www.medicareresources.org/medicare-part-d-coverage-gap/
[2] Centers for Medicare & Medicaid Services. Final CY 2026 Part D Redesign Program Instructions. April 7, 2025. https://www.cms.gov/newsroom/fact-sheets/final-cy-2026-part-d-redesign-program-instructions
[3] Medicare.gov. Medicare Prescription Payment Plan. 2025. https://www.medicare.gov/prescription-payment-plan
[4] KFF. 8 Things to Watch for the 2026 ACA Open Enrollment Period. October 2025. https://www.kff.org/affordable-care-act/8-things-to-watch-for-the-2026-aca-open-enrollment-period/
[5] KFF. ACA Marketplace Premium Payments Would More than Double on Average Next Year if Enhanced Premium Tax Credits Expire. September 30, 2025. https://www.kff.org/affordable-care-act/aca-marketplace-premium-payments/
[6] healthinsurance.org. 2026 Obamacare subsidy calculator. November 2025. https://www.healthinsurance.org/obamacare/subsidy-calculator/
[7] Center on Budget and Policy Priorities. If Enhanced Marketplace Tax Credits Expire. November 2025. https://www.cbpp.org/research/health/if-enhanced-marketplace-tax-credits-expire
[8] Centers for Medicare & Medicaid Services. Navigator and Certified Application Counselor Training. 2025. https://www.cms.gov/marketplace/outreach-and-education/navigator-certified-application-counselor
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