Softheon Medicaid

Medicaid is expanding, are you?

Our solution answers your concerns related to premium billing and payment requirements for Medicaid expansion. With states continuing to expand Medicaid and the new 1115 & 1332 Waivers, we are here to help you manage and implement the new requirements through our configurable, vertically integrated platform.

Why Softheon?

Partner with experts in government sponsored insurance

Billing & Payments

Medicaid is beginning to require premiums for recipients, and as a result, Softheon Medicaid contains a full Premium Billing and Payments solution to manage these.

Built-in Compliance

Softheon’s Medicaid Cloud offers government-grade compliance with our NIST 800-53, FIPS-140, MARS-E 2.0, PCI and HIPAA-compliant cloud.

Configurable Rules

We know that each state implements Medicaid differently. With Softheon Medicaid, you gain access to all existing configurations, and where configurations don’t exist, our rule-based engine will take care of it.

Eligibility & Enrollment

A no wrong door approach determines Medicaid eligibility through our end-to-end enrollment experience. Once deemed Medicaid eligible, Softheon Medicaid manages all backend rule configurations to determine and process ongoing status.

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We offer a full-suite PCI DSS 3.1 payment/banking platform that connects with all major card brands and other payment channels (cash, money orders, etc.), including Fiserv and MoneyGram, to support our issuers. As a designated Payment Facilitator, we can also quickly and conveniently process payments without any third-party involvement. Members can manage their digital wallets to support single and reoccurring payments.




Softheon finance allows you to track Medicaid premiums and Accounts Receivable, as well as provides support for payment interface files required by states to track member delinquency and status through the process. In addition, managing general ledger and month/year-end closing has never been easier with fully integrated accounting functions and a full suite of financial reports.

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Member Communications

Presentment and fulfillment of all state-required regulatory letters, as well as all other member touchpoints to enhance consumer engagement, can be delivered in either paper or paperless documents. First and second warning, Medically Frail, Pregnancy, Community Engagement, etc. are supported by this platform.


Payload Management

EDI Gateway

Integrate your claims administration platform with state Medicaid systems without having to make any changes to your existing infrastructure. Softheon Payload Management facilitates data exchanges through secure, real-time APIs, as well as standard and ad-hoc file types, including EDI 834.

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Data Intelligence & Governance

Softheon’s data intelligence suite offers intuitive state-of-the-art tools for all members of the health plan from the C-Suite to the individual contributor. Users can analyze data in near-real-time reviewing transaction trends, member demographics, geography, financial information, and cost comparisons. Softheon Governance manages all facets of reconciliation to keep your Medicare data in sync with downstream systems.


Join Softheon

Trusted by over 55 Health Insurance Issuers

Have more questions?

Check out our FAQ for more details on our solutions.