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In the ACA, adapting to change is not just a strategy; it’s a necessity.

The recent transition of a national health plan from Federally Facilitated Marketplace (FFM) to State-Based Marketplace (SBM) offerings in Virginia for the 2024 plan year stands as a clear example. This blog provides a glimpse into this journey, showcasing how the right technology and partnerships can simplify complex transitions. For the full story, download the case study.

Partnering to Meet a Tight Schedule for Exchange Transitions

The national plan faced a daunting task: adapting to Virginia’s move from an FFM to an SBM.

This shift required a significant overhaul of product filings, electronic data interchange (EDI) processes, and reconciliations from CMS to Virginia’s Insurance Marketplace, necessitating agility in adopting new secure file transfer protocols (SFTPs).

To navigate these financial and operational challenges, the health plan formed strategic alliances with experienced technology vendors. This included partnerships with GetInsured, a seasoned provider for eight SBMs, and Softheon, known for managing 100+ health plans’ ACA operations. The combined expertise and history of working together facilitated a smooth transition between health plans and state exchanges.

With Softheon’s comprehensive shopping, enrollment, and billing capabilities, the health plan efficiently migrated to Virginia’s Insurance Marketplace. Softheon’s all-in-one platform streamlined various processes, such as:

  • SFTP testing
  • Coordinating 834 transfers
  • Handling renewals
  • Managing policy-based payments

This integration not only saved time and effort but circumvented the need for creating new Application Programming Interfaces (APIs).

Keeping Members in Mind: A Model for Successful Adaptation

As states increasingly move towards SBMs, the adaptability and foresight shown in this case become ever more essential. Member retention is paramount during such transitions.

The health plan leveraged Softheon’s communication strategies to inform members about the shift from HealthCare.gov to their own website. The introduction of PayNow capabilities was crucial in maintaining premium payment continuity, thereby boosting member satisfaction and retention.

The transition to SBMs presents health plans with enhanced autonomy and potential financial advantages, demanding readiness to preserve market share and exploit new opportunities. For a comprehensive understanding of how this transition was successfully managed and to gain insights into preparing your plan for similar shifts, download our full case study.