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Many small and mid-sized health plans recently entered the ACA Marketplace or considered capitalizing on this exciting opportunity. Plans that participated several years ago can re-enter the marketplace based on the latest developments and increased stability.

The Biden Administration promotes increased subsidies as a priority, potentially causing a boom in ACA membership.

Is your health plan prepared to set yourself up for success?

Consider these key areas as you prepare for an effective entry into the ACA Marketplace:

1. Ensure CMS and DOI Compliance Through Proactive Measures

The Centers for Medicare and Medicaid Services (CMS) and each state’s Department of Insurance regulations will be key to the longevity of your health plan in the ACA. These requirements consistently challenge health plans. Consider the following features of Softheon’s product:

  • Monthly reconciliation and ad-hoc files
  • CMS audits
  • Changes to letters and member communication requirements
  • Variations in state requirements that may affect your compliance with DOI requirements
  • Conversion in your state from the Federally Facilitated Marketplace to a State-Based Marketplace
  • Unexpected Special Enrollment Periods

2. Reconciliation Can Make or Break Your Plan

Without the proper reconciliation processes in place, ensuring timely reimbursement of CMS subsidy payments could create ongoing damage to your health plan. Not only do you need to reconcile with CMS and the state exchanges, but health plans also need to have the appropriate processes in place to keep your downstream systems in alignment.

Common challenges include:

  • Inaccurate enrollment data causing member abrasion
  • Delayed subsidy payments
  • Mismatch between upstream and downstream systems

The proper configuration of your tech ecosystem to align enrollment and financial data will ensure success. Keeping both sources in sync and building a true picture of your membership provides stability between CMS and your members.

3. Payment Card Industry (PCI) Compliance Can Pose New Challenges

Payment processors risk devastating data breaches and the dissemination of Protected Health Information (PHI). Allowing credit card payments requires additional security regulations and PCI certifications.

Upwards of 70% of ACA Marketplace members pay their monthly premium by credit card. Health plans cannot ignore the additional security measures necessary to keep credit card payments safe for ACA plans.

Before taking on the PCI scope internally, consider outsourcing your merchant solution with the appropriate controls and oversight.

4. Health Insurance Casework System (HICS) Processing Has Strict Requirements

Marketplace issuers must face reoccurring HICS cases.

They require tight turnaround times and strict documentation for CMS and show that your health plan made the member whole.

Health plans struggle most with their unpredictability. This makes workforce management essential to preventing over-extending your team members.

Empowering members to manage their own accounts through self-service can significantly lighten labor time supporting HICS processing.

Robust communication with members, including timely and accurate invoices and delinquency notices and payment grace periods, can help members resolve issues before they become HICS cases.

5. Seamless Integration Reduces Administrative Overhead and Provides a Consumer-Friendly Experience

Expanding into the ACA Marketplace requires extensive communication with a wide array of systems. These include both vendor systems and those built internally. Ineffective integrations can create cascading effects on member abrasion and satisfaction.

Separate systems that communicate inefficiently with each other produce invoice inaccuracies and other negative outcomes. Streamline your member enrollment, account management, and renewal with an end-to-end solution that is optimized to reduce your overhead.

Fully integrated solutions increase member satisfaction by reducing delays and errors caused by poor communication among back-end processes and vendors. By creating a central point of integration, health plans can enable upstream and downstream systems to manage their membership more effectively.

Integrated systems enable health plans to reduce member abrasion by:

  • Receiving subsidy payments in a timelier fashion from CMS.
  • Empowering members to pay their first month’s premium upon enrollment.
  • Starting recurring payments immediately after members enroll in a plan.

6. Put Yourself in a Position to Rapidly Respond to New Trends

Scalability enables rapid changes in product offerings and services that easily meet changing market demands.

Year-over-year, based on rates and several other factors, your position in the Marketplace will change. Are you considering how you will scale your solution and grow by 100% while managing the existing membership?

Changing subsidies and Individual Coverage Health Reimbursement Arrangements (ICHRA) could surge individual market enrollments.

Member retention was at an all-time high in the 2021 Open Enrollment Period. As health plan loyalty grows, it becomes more important to not only retain your members but identify and capitalize on growth scenarios. Tight communication and pre-established outreach strategies will help mitigate the risks associated with this evolving Marketplace.