The Big Three Considerations for 2027 Open Enrollment/Renewal Season

By: David Ostrowsky

While we’re soaking up the final weeks of summer, the fall—i.e., health plan open enrollment/renewal season—is quietly sneaking up on us. As a prelude to every healthcare broker’s and administrator’s favorite time of year, The Phia Group has put together a must-see list of items for your consideration:

A/I and Health Plans –  For better or for worse, artificial intelligence appears to be baked into healthcare administration for the foreseeable future. In just this decade alone, AI has been a nifty resource for not only expediting the creation of benefit plans but actually administering benefits and defending decisions. On a broader level, many healthcare professionals have leveraged that technology to carry out cost containment initiatives as well as streamline claims processing and appeal management work among so many other functions.

While A/I has also helped plan participants secure high-quality and reasonably-priced care—a  simply unfathomable concept a few short years ago—the development has been met with a healthy dose of skepticism by some healthcare practitioners and everyday Americans. Will some plans be inclined to harness A/I towards cutting corners in reviewing prior authorization requests and potentially even denying claims? With A/I having a solid foothold in operating rooms across America, will there be a greater prevalence of surgical errors (yes, even, misidentified body parts) that yield adverse outcomes for patients? Given the extreme sensitivity and confidentiality of medical data, could A/I trigger widespread data use without explicit consent—not to mention biased responses when certain population sectors are underrepresented in datasets utilized to manage A/I? These are just a few of the many questions that are top of mind for healthcare consumers as the 2027 open enrollment and renewal season dawns.

Denials, Disputes, Appeals and Rising Scrutiny – Perhaps partially due to the incorporation of A/I into many payers’ claim review processes (along with more and more algorithmic tools at their disposal), medical claims have been denied at a breakneck pace over the past several years, much to the ire of millions of Americans paying into their employer-sponsored health plans. While insurance carriers—and stop-loss carriers—need to protect themselves against unnecessarily absorbing drastic financial costs, American healthcare consumers have become wary of what they perceive to be business practices hindering their access to care. While it is challenging to uncover data regarding specific insurers’ denial rates, there is copious evidence that many denials have increasingly been overturned upon appeal, implying that care should have been greenlighted initially. Thus, it seems reasonable to believe that in 2027, the number of appealed claim decisions—both internally and externally—will only continue to rise . . . while discontent lingers.

The Current PBM Landscape – For decades, many Pharmacy Benefit Managers (PBMs), which negotiate savings on drugs with pharma companies, organize pharmacy networks, and process prescription drug claims, operated under the cover of darkness, channeling price obfuscation and arcane rebate systems to maximize profitability while eschewing regulation. However, at this hour, it appears that such tactics may be backfiring as both regulators and an increasingly cost-conscious general public have started to seriously scrutinize and even cast blame on PBMs, vehemently calling for greater (and regular) transparency into their business practice. In fact, this past June, the Centers for Medicare & Medicaid Services (CMS) issued a Request for Information (RFI) to gather information on the services and business practices of PBMs and their affiliates. More specifically, CMS sought input on critical provisions of the Medicare Part D PBM reforms enacted earlier in 2026, including the upcoming “delinking” requirements and new PBM data reporting obligations slated to become effective in 2028. Indeed, starting in 2028, PBMs would have to deliver annual reports chronicling drug utilization, pricing, pharmacy reimbursement, enrollee cost-sharing, direct and indirect remuneration, as well as overall plan spending and revenue retained by PBMs and their affiliates.

It’s anyone’s guess as to whether said requirements will fuel profound market changes; however, it seems logical to conclude that regulators will be able to glean some insight into PBM operations that could, perhaps, spark new regulatory and enforcement initiatives down the line.

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While there are, of course, many other issues that are at the forefront of healthcare consumers’ collective attention with autumn approaching, A/I, denials, and PBMs remain pressing matters, both in the short- and long-term. As such, The Phia Group can once again be a trusted resource in answering any questions you may have or providing further clarification.