Two coverage changes are converging on January 1, 2026, and both will show up at the front desk as patients whose insurance is not what the chart says it is. The first is the expiration of the enhanced premium tax credits for marketplace plans, which ends on December 31, 2025 unless Congress extends them. The second is the wave of Medicare Advantage plan terminations for 2026, with the annual enrollment period having closed on December 7.
A family medicine practice we work with pulled its active patient list by payer last week: 640 patients on marketplace plans and about 1,900 on Medicare Advantage, out of 9,000 active patients. Roughly a quarter of the panel is in a coverage category that may change in three weeks. That is the scale of the problem, and it is why this is an outreach article rather than a policy article.
Key takeaways
- Unless Congress acts, marketplace enrollees' premium payments roughly double on average in 2026. Expect some marketplace patients to arrive uninsured, some on high-deductible bronze plans, and some in networks you are not part of.
- Medicare Advantage members whose plans ended had until December 7 to choose; those who did nothing are in Original Medicare on January 1, and everyone in MA can switch once more between January 1 and March 31.
- Build four outreach lists now: marketplace patients with January visits, marketplace patients with chronic conditions and no visit, MA patients in terminating plans, and patients with active authorizations.
- Verify eligibility for every patient at every visit for the first six weeks of the year, and write down the self-pay policy before January, not after the first uninsured patient arrives.
The marketplace credits: what is ending and what it means
The American Rescue Plan Act of 2021 increased the premium tax credits for marketplace coverage and extended them to households above 400 percent of the federal poverty level. The Inflation Reduction Act of 2022 extended those enhancements through the end of 2025. They expire on December 31, 2025. Open enrollment for 2026 began on November 1, 2025 and runs through January 15, 2026 in most states, with a December 15 deadline for coverage that starts January 1, and the premiums enrollees are seeing already reflect the loss.
KFF estimates that the average subsidized enrollee's premium payment would more than double, rising about 114 percent from roughly $888 to $1,904 a year. The Urban Institute estimated in September that about 7.3 million people would leave marketplace coverage in 2026, with about 4.8 million becoming uninsured. Congress could still extend the credits, and an extension could be made retroactive to January 1, but as of this writing there is no law. Practices should plan for the expiration and be pleasantly surprised if it does not happen.
What it means in the office: some marketplace patients will not renew and will arrive uninsured. Some will drop to a bronze plan with a deductible of several thousand dollars. Some will switch carriers to find a lower premium, and the practice may not be in the new network. All three look the same in the schedule until someone checks eligibility. A patient on a $7,000-deductible bronze plan who has a $180 visit in January owes the full $180, and the practice that does not say so before the visit will spend six months trying to collect it.
Medicare Advantage: who moves where
UnitedHealthcare, Humana and Aetna all exited counties for 2026, and several regional plans left markets entirely. Members whose plan is terminating were notified in October. If they picked a new plan by December 7, the new coverage starts January 1. If they did nothing, they return to Original Medicare on January 1 without a Part D plan unless they enrolled in one, and they have a special enrollment period to choose an MA plan afterward. The MA open enrollment period from January 1 to March 31 also lets MA members switch plans once more.
What it means in the office: the same patient may be Original Medicare in January, an MA plan in February, and a different plan in April. Each change affects the network, the referral rules, the prior authorization requirements and the cost sharing. A patient who was in a PPO with no referral requirement and moved to an HMO needs a referral from the primary care physician for the specialist visit already on the books for January 8. If nobody catches that, the specialist's claim denies and the patient gets a bill.
The outreach plan, in four lists
| List | How to build it | What to say |
|---|---|---|
| Marketplace patients with visits scheduled in January | Active patients with a marketplace plan on file and an appointment before January 31 | Ask them to confirm their 2026 coverage before the visit; tell them what the practice accepts; explain the self-pay option |
| Marketplace patients with chronic conditions and no visit scheduled | Same payer filter, no appointment, diagnosis of diabetes, hypertension, COPD, asthma or a behavioral health condition | Offer a December visit while coverage is certain; close open care gaps; refill 90-day prescriptions |
| MA patients in terminating plans | Active patients on plan IDs that end in your counties (your MA plans can supply the list) | Ask what plan they chose; confirm the practice is in that network; explain referral and authorization changes |
| Patients with active authorizations for recurring services | Authorization log, end date after January 1 | Explain that a new plan should honor the authorization for 90 days under the insurers' January 2026 commitment; collect the old authorization details |
Size the work before you start. For a marketplace panel of 640 patients, the first list will typically run to 100 or so and the second to about the same, and two front desk staff can call lists that size over four afternoons, reaching most patients and sending a text or portal message to the rest. An MA panel of 1,900 might have a few hundred patients in terminating plans; a mailed letter plus a portal message covers them, with phone calls reserved for the ones who already have January appointments. Plan the staffing in hours, put it on the calendar, and it gets done. Leave it as a good idea and it does not.
Close the gaps before the coverage changes
December is the last month of the 2025 measurement year for quality programs, and for a marketplace patient it may be the last month of coverage. The second list above matters for both reasons. A patient with diabetes who has not had an A1c, a retinal exam or a nephropathy screening this year, and whose coverage may lapse in January, should be offered a December appointment. This is good care and good quality performance, and it happens to be the visit that is easiest to get paid for. Our gaps in care work with practices is always busiest in December for this reason.
The same logic applies to prescriptions. A 90-day supply filled on December 20 under current coverage carries the patient into March, which is long enough for them to sort out new coverage or for Congress to act. Ask prescribers to review the refill list for the second-list patients this week.
January workflow changes
- Verify eligibility for every patient, every visit, for the first six weeks. Not just the ones flagged. A 270/271 check the day before the visit catches most changes; a real-time check at check-in catches the rest. Read the 271 for plan name and product type, not just active or inactive.
- Update the financial policy and the estimate script. Deductibles reset on January 1 and many are higher this year. Patients should hear an estimate before the visit and be asked for it at the visit.
- Write down the self-pay policy. A patient who has lost coverage needs a price, not a referral to the billing office. Decide the discount, the payment plan terms and who can approve exceptions.
- Route new-plan patients through a network check. If the practice is not in network with a new plan, the patient should know before the visit, not after the denial.
- Refresh the referral and authorization rules by plan. An MA member who moved from a PPO to an HMO now needs referrals; a marketplace patient who switched carriers now has a different authorization list.
Questions we hear
Should we tell marketplace patients to renew?
You can and should remind them that open enrollment is running, that December 15 is the deadline for January 1 coverage, and that coverage decisions affect their care. Do not advise them on which plan to choose; point them to the marketplace and to local navigators. The practice's job is to be clear about which plans it accepts.
What if Congress extends the credits in January?
Then patients who dropped coverage may re-enroll retroactively, and claims that were self-pay in early January may become billable to a plan. Keep the self-pay receipts and the encounter data clean so the claims can be created later. Refund the patient when the plan pays.
How much of this can be automated?
The eligibility checks, the list building and the reminder messages can be. The conversations cannot. Practices on our billing service get the four lists built from their practice management data in December, and our transformation team helps design the outreach scripts.
What to do this week
- Pull the active patient list by payer and build the four outreach lists.
- Call the marketplace patients with January visits and the chronic-condition patients without one; offer December appointments and 90-day refills.
- Send the MA terminating-plan letter and portal message, and call the ones with January appointments.
- Write the self-pay policy and the 2026 estimate script, and train the front desk on both before the holidays.
- Turn on day-before eligibility checks for every January appointment.
