Collecting patient balances after the 2026 deductible jump

What changed in patient cost sharing for 2026?

Deductibles jumped, more patients chose the plans with the highest ones, and fewer people have marketplace coverage at all. KFF found the average ACA marketplace deductible grew by 37%, or over $1,000, from $2,759 in 2025 to $3,786 in 2026, the steepest increase on record¹. The driver was the expiry of the enhanced premium tax credits, which pushed enrollees toward cheaper plans with higher cost sharing¹.

Plan selection shifted with it. Bronze plans went from 30% to 40% of selections, 7.3 million to 9.2 million people, while silver fell from 57% to a record-low 43%, 13.7 million to 9.8 million¹. Cost-sharing reduction silver plans, the ones that cut deductibles for lower-income enrollees, fell to 37% of enrollees¹.

Then enrollment itself fell. Individual market enrollment dropped from 25.2 million in June 2025 to 20.5 million in June 2026, 4.6 million people or 18%, and marketplace effectuated enrollment fell 12% in 2026, from 21.8 million to 19.2 million². Across states, Ohio and Oklahoma fell by just over 32% while New Mexico, with its own state subsidy, was the only state to grow, and average premium payments rose 58%³. Some of those people are now self-pay at your front desk.

Medicare moved too, more gently. The Part B deductible rose to $283 in 2026, up $26 from $257, and the standard Part B premium rose to $202.90 from $185.00⁴.

How do you read remaining deductible and coinsurance on the eligibility response?

Look for the deductible section of the 271, which for most payers shows the plan-year deductible, the amount already met and the remaining balance, along with the coinsurance percentage and any copay by service type. Run it the day before the visit, not the week before, because a patient who saw another provider on Tuesday has a different remaining deductible on Thursday.

Three fields matter at the desk: remaining deductible, coinsurance percentage, and whether the visit type carries a copay instead. Write them on the schedule or in the appointment note so the front desk sees them without opening the payer portal. The deductible glossary entry explains how plan-year and calendar-year deductibles differ, which decides when the remaining balance resets.

When a payer returns a plan-level figure without the remaining amount, call or use the portal, and record what you were told and when. Eligibility verification run by a dedicated biller does exactly this for the next day’s schedule and flags the patients whose remaining deductible exceeds the expected allowed amount.

When should you ask for payment: before, at or after the visit?

Before, for the part you can estimate; at the visit, for the copay and any known balance; after, only for the part that depends on adjudication. The order matters because each later step costs more to collect and collects less.

Before the visit means a call or text a day or two out that says what the visit is likely to cost and why. For a patient with an untouched $3,786 deductible, that conversation is the difference between a surprise statement in March and a planned payment in January. At the visit, collect the copay and the estimated share within what your payer contracts allow at the time of service, and refund any overpayment once the claim pays.

After the visit is for coinsurance on an allowed amount you didn’t know in advance, and for the gap between the estimate and the adjudicated claim. Keep that gap small and the statement is a confirmation rather than a shock.

Here’s the trade-off: asking for money up front costs you some goodwill, and a few patients will reschedule or leave. Not asking costs you the balance. AAFP’s benchmark for the adjusted collection rate is 95% at minimum, with an average of 95% to 99%⁵, and in a high-deductible year the patient share is where that number is won or lost.

What does a clear estimate conversation sound like at the front desk?

A clear estimate conversation at the front desk is short, specific and in the patient’s words, naming the deductible, what today’s visit usually comes to with the patient’s plan, and the choice between paying now and setting up a payment plan. “Your plan has a $3,786 deductible and your insurer shows you haven’t met any of it yet. Today’s visit usually comes to about this amount with your plan, so you’d pay that today and we’ll adjust it if your insurance pays differently. Would you like to pay now or set up a plan?” That’s three sentences, and every figure in it came from the 271 and your fee schedule.

Avoid three things: quoting your full charge when the contracted allowed amount is lower, saying insurance will cover it when the deductible says otherwise, and using the words deductible and coinsurance without a one-line explanation. A patient who understands why they owe money has fewer reasons to dispute the statement later.

Write the script down and train everyone who answers the phone on it. The patient responsibility entry gives plain-language definitions the front desk can borrow.

How do statements, payment plans and reminder calls fit together?

Statements, payment plans and reminder calls fit together as one calendar: a statement goes out the day the claim adjudicates and the patient share is final (day 0), a reminder statement or text at day 30, and a call at day 60 with a payment plan offer. Payment plans should be a rule, not a negotiation: a minimum monthly amount and a maximum number of months, offered to anyone over a set balance.

The reminder call is the step practices skip, because nobody has time to make it. Practices that cannot staff reminder and balance calls sometimes route them to a virtual front desk service that answers in the practice’s name, books appointments and handles reminders and after-hours calls. Whoever makes the calls, they need the same three facts: the balance, the date of service, and the payment plan terms.

Patient billing support as a service is the statement cycle, the calls and the plan tracking run by a dedicated biller, with patient-balance aging reported to the owner weekly. Watch patient balances over 90 days as a share of the total; when it climbs, statements are going out late or the estimate conversation isn’t happening.

Which patient responsibility codes tell the biller what to bill the patient?

The PR group code on the 835, with the claim adjustment reason code beside it. X12 maintains the list, and the group codes are CO for contractual obligation and PR for patient responsibility⁶. The three PR codes you’ll see most are 1, 2 and 3, which identify the portion that is deductible, the portion that is coinsurance and the portion that is a copay⁶.

The rule is simple: PR amounts are billable to the patient, CO amounts are not. A CO-45 adjustment, the difference between your charge and the contracted amount, is written off⁶. A PR-1 amount is the deductible the patient owes. The PR-1 page walks through the posting steps, and PR-2 and PR-3 have their own pages.

Two posting errors to watch: a PR amount posted as a contractual write-off hides money you’re owed, and a CO amount posted to the patient produces a statement they shouldn’t get. Reading the group code every time prevents both.

What to do this week

1. Pull the 271 responses for next week’s schedule and check which payers return remaining deductible; call the ones that don’t.
2. Write the three-sentence estimate script and put it at every front-desk station.
3. Set the payment plan rule: minimum monthly amount, maximum months, minimum balance to qualify.
4. Check that your payment posting maps PR-1, PR-2 and PR-3 to the patient and CO-45 to the contractual write-off.
5. Add patient balances over 90 days to the weekly report.