Understanding US Healthcare Affordability: What Millions of Eligibility Checks Reveal About Patient Cost Exposure

We’re excited to announce the launch of Blue Card Eligibility Identification - a new capability designed to improve network status accuracy and reduce ambiguity when working with BCBS plans.

Growing practices are discovering that manual eligibility verification that worked for 500 patients becomes unmanageable at 5,000. Administrative teams that once handled coverage checks efficiently find themselves overwhelmed. There are effective strategies to grow without these issues

Many practices try to patch over the problem with overtime or additional hires, or offshore solutions. But the relief is only temporary before you start seeing the same problems resurface. Here are four specific patterns that signal you've hit the tipping point where it’s time to consider automating.

Medicaid enrollment is expected to decline sharply over the next two years as these policies take effect. The Congressional Budget Office projects work requirements alone will generate $326 billion in federal savings through millions of patients losing coverage - when those patients can’t pay, their bill will become bad debt

Patients are dropping marketplace plans, shifting to Medicaid or employer coverage, or going uninsured. New sign-ups are down considerably in Pennsylvania and California, and state-based exchanges saw an 18% decrease in new customers overall.

H.R. 1 (the "One Big Beautiful Bill" Act) delivered the largest Medicaid restructuring in decades. The government shutdown delayed implementation guidance, but the CMS moved fast once the lights came back on - releasing two major guidance documents within a week of the November 12 funding resolution. The Congressional Budget Office projected $225.7

This month we rolled out updates that make eligibility data more consistent across OneVerify and the API–especially for plan classification and reporting–right in time for year-end and benefit resets. We’re also expanding Workflow Management and sharing key payer shifts from our billing team to help you stay ahead.

Regulatory changes between 2024 and 2025 lowered out-of-pocket maximums in many states, which in theory makes care more affordable. In our eligibility dataset, we see that average out-of-pocket maximums dropped 36.8%, from $7,788 to $4,926. Coinsurance rates decreased 6.2%, from 16.5% to 15.5%. Both reductions should have lowered what patients pay

For this piece, we’ve chosen to present the data on a state-by-state basis, showing the average across government and commercial plans within each state. This approach allows us to highlight national trends and patterns that we have observed.