Skip to main content

Over one million members transitioned to a new health plan following the Bright Health exit. Most of them found a new home with a Softheon-partnered health plan.

Read more to learn how successful health plans can capitalize on market opportunities.

From carrier exits to policy changes, health plans must have the flexibility to pivot and accommodate enrollment influxes to make the most out of the dynamic ACA Marketplace.

Health Plan Technology Spend in 2023 Compared to 2022, According to Gartner® Infographic: Top Priorities, Technologies and Challenges in Insurance in 2023 [1]

Cloud-Based Platforms

70% ꝉ

Application Modernization

57% ꝉ

Integrated API Architecture

57% ꝉ

The Total Experience

57% ꝉ

Bright Health’s Withdraw Paves the Way for Health Plan Expansion in 15 States

Bright Health withdrew from the Marketplace in 15 states right before Open Enrollment (OE) 2023, leaving a large industry gap of over one million individuals.

States that Saw a Spike in Enrollment Growth with the Bright Health Exit

Enrolling Hundreds of Thousands of New Members Practically Overnight: Secrets of Successful Health PlansHealth plans with a strong market presence in these states have already started reaping the benefits.

Softheon Clients in Affected States Saw:

A Rapid 236 – 9,197% ꝉ in Membership Compared to OE 2022

Hundreds of Thousands of New Enrollees in Two Weeks

However, many health plans might not be able to capitalize on the Bright Health exit due to a lack of system flexibility. Accommodating tens of thousands of new members overnight is difficult for health plans that rely on manual processes or inflexible, disparate systems. Especially as new health plans enter to take advantage of potential growth, leadership must invest in scalability to meet market demand.

Opening the Floodgates: Automating the 834 Process to Achieve Increased Effectuation Rates

When effectuating past Bright Health members, Softheon maintained its SLAs by processing 99.9% of enrollment transactions on the same day. Here’s how.

Working with multiple integration points (the Federally Facilitated Marketplace, State-Based Marketplaces, and various third-party brokers) can make processing enrollment data automatically very difficult.

Although the 834 has an “industry standard,” there are several ways to interpret values, also known as “mutually defined.” For some exchanges, that could be a subscriber ID, for others, it could be a policy ID. Additionally, there are segments considered “situational,” meaning they’re dependent on others being present. For different exchanges, these dependencies can differ. This can make data normalization complex and difficult.

To streamline the 834 processes, Softheon clients invested in a modular, off-the-shelf (OTS) process that takes advantage of established APIs and data normalization best practices.

By rearranging enrollment data on the Softheon platform, all files can be reviewed and processed the same way. When 834 files arrive, each transaction is represented by a folder entity in our system. Once the data is imported into these folders, called member details, normalization processes and rearranges the data into a uniform state. 

The member detail folder is a translation of the various loops and segments from the 834, specifically the 2000-2750 loops for each specific member of the transaction set. Doing this allows Softheon to process the data throughout the entire end-to-end workflow in the same manner, so every successive step can map to the same value in the member detail folder, regardless of which data source sent it. 

Having an automatic workflow that normalizes, preserves, and reconciles the enrollment data grants system flexibility. Sudden influxes of members, as seen during the Bright Health exit, have no impact on system performance.

Technology Matters: High Member Engagement and Robust Broker Networks Are Key

Softheon clients saw a 1.5% higher member effectuation rate compared to the industry average during the 2021 plan year. Technology and systems can impact member (and broker) behavior, such as keeping a larger percentage of newly acquired members.

Health plans that enrolled the majority of Bright Health’s membership utilized a Software as a Service (SaaS) communication and outreach solution. That’s in contrast to the business process outsourcing (BPO) model, which may not scale as well with sudden surges.

Top-performing health plans kept more Bright Health members by investing in automation, broker appointments, and digital engagement strategies.

During the weeks following Bright Health’s exit, some carriers struggled to communicate with potential members. Individuals received an influx of confusing messaging regarding their coverage from Bright Health, CMS, and the new plans.

Some plans were more ready than others. Aetna had already achieved 50%+ digital engagement rates.

Paul Wingle, the Vice President of Individual & Family Plans at Aetna/CVS Health, spoke with Softheon about communication changes that Aetna made to adapt to the individual market. Health plans are no longer dealing with specialists who have a deep understanding of the market and must prepare to do some extra handholding.

This notion of a guided enrollment process is even more critical during high-stress situations like Bright Health’s exit.

An omnichannel approach to communication includes outreach through emails, mobile apps, online portals, texts, and many more. A scalable, unified approach to messaging can be very difficult to achieve and requires consistent optimization and actionable measurement.

Decision tools, consistent outreach, and healthcare education all help empower members to make informed choices and increase effectuation rates by making sure individuals don’t fall through the gaps.

Broker-assisted enrollments account for 55%+ of ACA enrollments. For some plans, it’s as much as 70%.

While some plans wish they could eschew brokers, ignore them at your peril. Some plans lost 1/3 or more of Bright Health members due to not having a wide enough broker network and failing to appoint brokers promptly. Those brokers took their members to appointed plans.

Building for Adaptability: Key Steps to Achieving Technology Modernization

Softheon’s clients achieve higher than average effectuation and retention rates largely due to highly composable architecture. Here is where experts say health plans need to invest to adapt to a changing market

Investing in composability and technology modernization allows health plans to capitalize on changes within the market and adjust to meet shifting regulations. Avoiding frequent infrastructure overhauls reduces administrative and technology overhead, freeing resources to pursue new opportunities with relative ease.

Struggles health plans aim to solve with the composable solutions model include:

  • Inability to scale operations to raising enrollment rates.
  • Resources spent trying to rapidly meet changing regulations.
  • Lack of communication and data transfer between different solutions.
  • Failure to capitalize on expanding markets due to limited flexibility.

Inherent flexibility and scalability allow for rapid membership growth.

Half the battle of running a business within the healthcare industry is knowing when to adapt and change. Growth and scalability only occur when you have an operations model that can accommodate industry shifts and the foresight to identify when it’s time to zig or zag. Technology continues to be the ever-changing force behind how your business adapts to today’s environment.

The composable architecture approach breaks down the traditional silos of computing, storage, or networking. It reveals that what was once “hardware” isn’t hardware at all but just a set of services that can be configured and allocated based on changing requirements throughout the day.

That’s when having a composable infrastructure can come in handy, particularly within the healthcare industry.

Prepare for future growth by ensuring your vendor possesses the technology needed to scale with your ACA membership. Due to the rapid rate at which the health insurance technology field evolves, health plans must always have their sights set years in advance, constantly on the lookout for what will put them ahead of the competition.

Gartner® recommended the following steps [1] for health plans looking to grow through technology modernization:

  • Analysis gaps between company goals and technological initiatives
  • Align technology initiatives to specific goals
  • Get approval from CEOs and other stakeholders

For assistance at any step of this process toward technology modernization, Softheon can help. Our team of healthcare experts has worked with over 90 health plans to create modified OTS solutions for complex operational processes.

Email with questions about system modernization.

[1] Gartner, Infographic: Top Priorities, Technologies and Challenges in Insurance in 2023, Kimberly Harris-Ferrante, October 19, 2022.