Your Deductible and MOOP Strategy for Next Year Starts Now

By: Brian Choate, Co-Founder & Managing Partner, SGS

Health benefit costs are on pace to rise 6.7% in 2026, pushing the average cost above $18,500 per employee, according to Mercer. Employers are responding the way they usually do: 66% of large employers say they're likely to raise premiums next year, and about half plan to increase cost sharing through higher deductibles and out-of-pocket maximums. Whatever an employer doesn't absorb, the employee does, and whatever the employee doesn't absorb up front, the provider ends up chasing after the fact.

For providers treating emergencies, there's no point of service where that cost sharing can be addressed. A patient's deductible and MOOP status isn't something anyone can check mid-crisis, and it isn't something a provider can collect on before treatment. That means next year's strategy has to be decided now, before the higher deductibles and out-of-pocket maximums show up in claims, not after.

Here's specifically how that strategy works: not every claim needs active management. Most patients are either well under their deductible or already past their MOOP, and those claims move through as normal. The claims that need attention are the ones sitting in between, where a patient's remaining deductible or out-of-pocket balance genuinely affects whether a charge lands on the patient or on insurance. Managing every claim the same way, regardless of where a patient stands, creates administrative burden without adding value. Managing only the claims where deductible and MOOP position actually changes the outcome is what makes the strategy sustainable.

For those claims, the same principle applies: monitor where the patient stands on their deductible and MOOP as other claims from an episode of care post ahead of ours, and release the claim at the point where that positioning works in the patient's and the provider's favor.That's targeted management, not blanket process. It adds a decision point only where a decision actually changes the outcome, and leaves every other claim to move through untouched.

With premiums and cost sharing both rising again in 2026, and going into 2027 by the look of Mercer's numbers, this isn't a one-time adjustment. It's a strategy that needs to be reassessed every renewal cycle, because the terrain it's built for keeps shifting under it. Providers who build that reassessment into their process each year are the ones who keep the burden off the patient and off their own collections desk. Providers who wait until claims start bouncing back unresolved are managing the problem after it's already cost them.

If you want to talk through what a deductible and MOOP management strategy could look like for your organization, reach out to our team. We'll walk you through how our process works and where it could fit into next year's plan.

Source: SHRM/Mercer, "Health Benefit Costs on Pace to Rise 6.7% in 2026," July 2026.