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The ACA is here to stay.

And so is the national carrier that rapidly expanded its footprint during the 2023 Open Enrollment (OE) period.

Many carriers, both regional and national, faced significant challenges in maintaining profitability in the years following the inception of the ACA. Carriers encountered obstacles in adapting to the new regulatory framework, managing increased enrollment volumes, and navigating the complexities of the evolving healthcare landscape.

However, the dynamics of the ACA have undergone substantial improvements since its early stages. The Marketplace demonstrates increasing stability and growth, presenting a favorable environment for carriers considering entry or expansion. Lessons learned from past experiences, coupled with advancements in technology and infrastructure, have significantly reduced the risks associated with entry.

Recognizing the renewed opportunity within the ACA, a national health plan made a strategic decision to seize the moment and expand responsibly.

Maximizing Success Safely: Strategies for responsible scaling in the ACA

Relying on manual processes hinders growth and can lead to disasters. Lessons from past experiences emphasize the risks of being unprepared for unexpected success.

A prime example is the aftermath of Bright Health’s exit, which left a gap of over one million individuals. Achieving success in the healthcare industry requires careful planning of effective pricing strategies, alongside operational efficiency.

However, it is essential to note that health plans utilizing Softheon’s shopping, enrollment, and billing platforms seamlessly enrolled a significant portion of ex-Bright Health members.

With the ACA undergoing frequent changes, it becomes challenging to anticipate the circumstances that demand scaling up. Recent years have witnessed substantial marketplace impacts caused by sudden carrier exits, subsidy expansions, and Medicaid redetermination.

Exponential Growth: Achieving 2,400% membership growth between OE periods

Automated operations allow health plans to scale past initial projections.

One ACA entrant achieved a 2,455% membership increase between OE periods by implementing streamlined back-end operations and delivering an intuitive member journey. Again, taking advantage of changes in the market that happened unexpectedly.

By leveraging expertise and automated processes, health plans can avoid the growing pains that plagued early ACA entrants.

Download our full use case to learn how a national carrier kept HICS cases low during periods of rapid membership growth and next steps for expansion.