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

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.

Behind the Claims is a series celebrating the partners who power healthcare operations behind the scenes. Nirvana’s technology is built by billers, for billers—and we understand how essential it is to have systems that truly work for the people and organizations using them. Healthcare is ultimately powered by people.

Forget ghosts and ghouls. The real horror stories unfold every day in healthcare billing offices across America. Endless phone trees. Contradictory reps. Portals that promise automation but deliver chaos. What follows isn’t fiction. These are real accounts from online forums, retold as billing horror stories because, frankly, that’s what they are.

This month we launched Behind the Claims, continued our roll out of Annual Benefit Reset automation, were featured in the Out-of Pocket Healthcare Newsletter and welcomed Robert Andrews to our Advisory Council.

Behind the Claims is a series celebrating the partners who power healthcare operations behind the scenes. Nirvana’s technology is built by billers, for billers—and we understand how essential it is to have systems that truly work for the people and organizations using them. Healthcare is ultimately powered by people.

Radiology faces unique eligibility challenges: expensive procedures paired with complex prior authorization requirements that cause cascading delays and disrupt patient care continuity. Organizations investing in comprehensive eligibility solutions see significant improvements in patient satisfaction and operational efficiency