When policy changes, patients feel it first: Why eligibility and self-pay matter more than ever

While financial challenges seem perpetual for most healthcare providers, 2026 brings some unusual revenue uncertainty as the year gets under way. Significant regulatory changes affecting ACA marketplace plans are driving that unpredictability. Enhanced premium tax credits for exchange-based health plans have expired. Families that relied on the credits to make high quality coverage affordable may now be priced out and turn to high-deductible plans or catastrophic coverage.  Initial federal data show enrollment in plans offered through the federal marketplace was down more than 1.2 million from last year’s enrollment period.[i] Several state-run exchanges, including California, Minnesota and New Jersey, reported enrollee shifts to high-deductible bronze level plans.[ii]

In addition, all ACA premium tax credits are subject to new requirements, such as no automatic renewal of credits and more stringent income verification.  These shifts in the commercial market come on top of looming Medicaid eligibility changes. These include redetermination screenings every six months instead of annually and work requirements.

The implications for providers are increased volumes of self-pay patients, higher patient responsibility amounts and potentially higher costs to collect and more bad debt write-offs. The Robert Wood Johnson Foundation estimates providers will face more than $32.1 billion in lost revenue and a $7.7 billion spike in uncompensated care in 2026 from expiration of the enhanced ACA premium credits alone. That’s significant financial pressure added to the higher labor and supply costs providers are experiencing.

While the impact of these changes will be different for every facility, based on location, patient volume and payer mix, some actions make universal sense. Providers that make aggressive moves to enhance upfront eligibility verification and financial counseling will be well positioned to mitigate the impact of expiring credits and other ACA changes. Cost effective options include automation, chatbots, AI-based agents and even financial counseling chatbots. In our experience, the investments necessary to shore up these revenue cycle components will be offset with protected revenues and optimized reimbursements.

Here are practical steps providers can take now:

Expanding eligibility and benefits verification.

Anywhere from 3.8 million to 4.8 million people are expected to go without health insurance in 2026 due to the expiration of enhanced premium tax credits and more expensive plan premiums.[i] This is in part because many patients may find unsubsidized plans unaffordable yet have earnings too high for Medicaid eligibility. Younger and healthier people may also choose to go without pricey coverage. In this volatile coverage environment, providers must enhance verification of coverage and benefits to prevent claims denials stemming from delivering services while a patient was not covered or between health plans.

Avoiding this scenario may require providers to re-verify coverage throughout a patient’s course of treatment. Real-time tools are essential. Coverage verification now needs to happen when patients first schedule an appointment or procedure; before the date of service; on the actual date of service; and then again before a claim is submitted. Providers must be especially vigilant about reviewing whether a patient is in a three-month ACA plan grace period and initiate financial conversations with these patients.

Providers can accomplish these multiple verifications efficiently by tweaking automation tools to manage these tasks instead of increasing headcount. Eligibility service providers should help providers make optimal choices in whether to use onshore or offshore resources.

Providers also must have strategies ready for when a patient’s coverage does change or drop.

That brings up the next point.

Offer financial counseling and payment plans.

Providers can protect revenues while ensuring access to care by having counselors equipped to help patients understand all their financial options, from charity care to state financial assistance programs to installment payment plans. Publicizing availability of payment plans and counseling may also encourage patients to continue to use providers’ preventive care and chronic condition management services. Maintaining continuity of care should help providers and patients avoid much more expensive urgent care and emergency department visits.

Success in this step requires excellent communication between the front and back end of the revenue cycle. It also requires front office personnel to be extremely knowledgeable about state assistance programs, such as high-risk pools, and other financial options, ranging from drug company assistance programs for specific conditions to local charitable options.

Propensity to pay scoring logic can help financial counselors understand which payment options will be most effective with specific patients, such as adaptive or adjustable payment plans and lower terms on repayment. Diverse payment options also enhance patient satisfaction and retention, along with better collection rates. Options include payment portals, card on file, IVR and text payments.

Providers may also partner with non-profit organizations to put on community events to help patients navigate their options in person, especially during open enrollment periods.

Partner with experienced revenue cycle management specialists.

Identifying patients is likely to be affected by expiring subsidies and shifting coverage requires staff training and resources many providers may be stretched to deliver. Similarly, the likelihood of managing increased denials, self-pay and patient responsibility amounts will strain business office staff. Partnering with experienced revenue specialists who have the knowledge and tools to address new revenue cycle challenges will be the most cost-effective solution for many providers. A service provider should have real-time tools, AI capabilities and expert staff to augment a provider’s own capabilities. Together, they can mitigate the impact of ACA marketplace shifts and eventually, the new Medicaid regulations.

In our experience, healthcare systems with strong financial navigation programs help their patients retain access to care while also improving accounts receivable and self-pay collections. A provider we worked with saw a 49% increase in upfront collections just six months after implementing better patient communication about cost estimates, while upfront collections increased 304% after the first full year of the program.

While expiring ACA tax credits are an immediate concern, new payment models and shifting risk will continue to affect revenues. The good news is providers can effectively strengthen their revenue management approach, focusing on eligibility and self-pay, to reduce these financial risks and ultimately help ensure they continue delivering high-quality patient care.